Perceptions of Military Experience Among Veterans Reporting Lifetime Warzone Moral Injury

ABSTRACT

Exposures to potentially morally injurious events (PMIEs) and possible moral injury are risk factors for a range of difficulties impacting individual functioning. Although exposure to PMIEs is a somewhat common product of war, qualitative methods to understand Veterans' experiences of moral injury and Veterans Affairs treatment are limited. To better characterize Veterans' experiences, 14 male warzone Veterans who reported moral injury post-warzone deployment and completed posttraumatic stress disorder treatment in the past year were asked to describe their military service as part of a qualitative study. Through thematic analysis, we found two moral injury-consistent themes and four subthemes. The first theme was "military experiences were associated with morally questioning one's self" with subthemes of "moral shift" and "depersonalization." The second theme was "military experiences were associated with morally questioning others" with subthemes of "disillusionment" and "resignation." Based on these findings, we conclude with a discussion of treatment implications for moral injury.

Traumatized German soldiers with moral injury - value-based cognitive-behavioral group therapy to treat war-related shame

Introduction

During deployment, soldiers are confronted with potentially morally injurious events. In many cases, these events violate their personal values and belief systems, resulting in feelings of anger, alienation, guilt, and shame. The psychological distress caused by such transgressions is defined as moral injury. It remains unclear to date, which therapeutic interventions are most appropriate for addressing this specific psychological condition. This study examines the effectiveness of value-based cognitive-behavioral group therapy combining elements of cognitive-behavioral therapy, acceptance and commitment therapy, spiritual care, and adaptive disclosure therapy.

Materials and methods

This controlled study uses the Compass of Shame Scale to assess symptom severity among participants both before and after a three-week inpatient group therapy regimen for moral injury. An intervention group (n = 45) was compared to a waiting-list control group (n = 40). A one-way between subjects ANOVA was conducted to determine the differences between the two measurement points in the intervention group compared to the control group. A positive ethics vote from the Humboldt University Berlin (Charité) was available (No.EA1/092/15).

Results

A significant difference was found on the shame-associated maladaptive strategies subscales of attack self (F (1, 83) = 5.942, p = 0.017, Cohen's f = 0,27), withdrawal (F (1, 83) = 8.263, p = 0.005, Cohen's f = 0,32), and attack others (F (1, 83) = 10.552, p = 0.002, Cohen's f = 0,36) of the Compass of Shame Scale between the intervention group and the control group at the p < 0.05 level in the pre- and post-treatment (t1-t2) comparison.

Conclusion

This study suggests that the special therapeutic focus in cognitive-behavioral group therapy can alter shame-based maladaptive coping behaviors in response to war-related moral injury. This study provides further evidence that therapeutic approaches - through fostering a reconciliatory, compassionate, and forgiving approach toward oneself and others - target the underlying mechanisms of moral injury. Therefore, value-based cognitive-behavioral interventions should be considered as a standard element of trauma care in a military setting. Future studies should further examine such interventions in randomized control trials. It would also be particularly valuable for future studies to include a follow-up time point.

Negative cognition in the context of suicidality after exposure to military-related potentially morally injurious events

LAY SUMMARY

Moral injury (MI) refers to the psycho-spiritual consequences of events that deeply transgress a person’s core moral beliefs and values. Such events are reportedly common in the military context, and strong associations have been demonstrated between exposure to potentially morally injurious events (PMIEs) and suicidality. This study explored differences in negative cognitions between treatment-seeking Canadian Armed Forces members and Veterans with and without current suicidal thoughts and behaviours (STBs), all of whom reported current distress in response to a PMIE. Those exhibiting STBs reported stronger negative beliefs about the self. Scores for event-related guilt cognitions and self-blame were similar across individuals with and without STBs. Individuals reporting STBs also displayed higher depression and symptoms of posttraumatic stress disorder. The results suggest that severity of mental health symptoms and negative self-evaluations may be most pertinent in their association with suicidality in the MI context. Results remain preliminary, however, and additional research is needed to properly examine how event and self-related evaluations affect suicidality after PMIEs.

The Moral Injury Experience Wheel: An Instrument for Identifying Moral Emotions and Conceptualizing the Mechanisms of Moral Injury

This paper introduces an infographic tool called The Moral Injury Experience Wheel, designed to help users accurately label moral emotions and conceptualize the mechanisms of moral injury (MI). Feeling wheels have been used by therapists and clinical chaplains to increase emotional literacy since the 1980s. The literature on the skill of emotion differentiation shows a causal relationship between identifying emotions with specificity and emotional and behavioral regulation. Emerging research in moral psychology indicates that differentiating moral emotions with precision is related to similar regulatory effects. Based on this evidence, it is proposed that increasing moral emotional awareness through use of an instrument that visually depicts moral emotions and their causal links to MI will enhance appraisal and flexible thinking skills recognized to reduce the persistent dissonance and maladaptive coping related to MI. Design of the wheel is empirically grounded in MI definitional and scale studies. Iterative evaluative feedback from Veterans with features of MI offers initial qualitative evidence of validity. Two case studies will show utility of the wheel in clinical settings and present preliminary evidence of efficacy.

Mindfulness to Manage Moral Injury: Rationale and development of a live online 7-week group intervention for veterans with moral injury

Background

Military service puts service members at risk for moral injury. Moral injury is an array of symptoms (e.g., guilt, shame, anger) that develop from events that violate or transgress one's moral code.

Objective

We describe adaption of in-person mindfulness training program, Mindfulness to Manage Chronic Pain (MMCP), to address symptoms of moral injury to be delivered live via the web. We discuss how we will assess benchmarks (i.e., recruitment, credibility and acceptability, completion rates, and adherence) of the Mindfulness to Manage Moral Injury (MMMI) program.

Methods

Aim 1: To develop and then adapt the MMCP program based on feedback from experts and veterans who took part in Study 1. Aim 2: To develop an equally intensive facilitator-led online Educational Support (ES) program to serve as a comparison intervention and conduct a run-through of each program with 20 veterans (10 MMMI; 10 ES). Aim 3: To conduct a small-scale randomized controlled trial (N = 42 veterans; 21 MMMI; 21 ES) in which we will collect pre-post-test and weekly benchmark data for both refined intervention arms.

Results

Study 1 and 2 are completed. Data collection for Study 3 will be completed in 2022.

Conclusion

MMMI is designed to provide a live facilitated mindfulness program to address symptoms of moral injury. If Study 3 demonstrates good benchmarks, with additional large-scale testing, MMMI may be a promising treatment that can reach veterans who may not seek traditional VAMC care and/or who prefer a web-based program.

Trajectories of functioning in a population-based sample of veterans: contributions of moral injury, PTSD, and depression

BACKGROUND

Although research has shown that exposure to potentially traumatic and morally injurious events is associated with psychological symptoms among veterans, knowledge regarding functioning impacts remains limited.

METHODS

A population-based sample of post-9/11 veterans completed measures of intimate relationship, health, and work functioning at approximately 9, 15, 21, and 27 months after leaving service. Moral injury, posttraumatic stress, and depression were assessed at ~9 months post-separation. We used Latent Growth Mixture Models to identify discrete classes characterized by unique trajectories of change in functioning over time and to examine predictors of class membership.

RESULTS

Veterans were assigned to one of four functioning trajectories: high and stable, high and decreasing, moderate and increasing, and moderate and stable. Whereas posttraumatic stress, depression, and moral injury associated with perpetration and betrayal predicted worse outcomes at baseline across multiple functioning domains, moral injury associated with perpetration and depression most reliably predicted assignment to trajectories characterized by relatively poor or declining functioning.

CONCLUSIONS

Moral injury contributes to functional problems beyond what is explained by posttraumatic stress and depression, and moral injury due to perpetration and depression most reliably predicted assignment to trajectories characterized by functional impairment over time.

Quantitative changes in mental health measures with 3MDR treatment for Canadian military members and veterans

OBJECTIVE

Military members and veterans are at elevated risk of treatment-resistant posttraumatic stress disorder (TR-PTSD) due to higher rates of exposure to potentially traumatic events during the course of duty. Knowledge of TR-PTSD is limited, and specific protocols or evidence-based TR-PTSD therapies are lacking. Multimodal motion-assisted memory desensitization and reconsolidation (3MDR) therapy is an emerging intervention for combat-related TR-PTSD. The purpose of this study was to preliminarily assess the effectiveness of 3MDR in addressing TR-PTSD in Canadian military members and veterans.

METHODS

This study is a longitudinal mixed-methods clinical trial. English-speaking military members and veterans aged 18-60 with TR-PTSD were recruited to participate. The intervention consisted of six sessions of 3MDR therapy. Quantitative data were collected pretreatment, posttreatment, and longitudinally at 1, 3, and 6 months after completion of 3MDR.

RESULTS

Results from the first 11 participants to complete the 3MDR protocol exhibited statistically significant improvement (surviving multiple comparison correction) in clinically administered and self-reported scores for PTSD (CAPS-5 and PCL-5), moral injury (MISS-M-SF), depression (PHQ-9), anxiety (GAD-7), emotional regulation (DERS-18), and resilience (CD-RS-25).

CONCLUSION

The preliminary and exploratory results from this clinical trial support the growing body of literature illustrating 3MDR as an effective treatment for military-related TR-PTSD. These results are notable given participants' previous lack of success with frontline psychotherapeutic and pharmacological interventions. Given that there are currently very limited treatment options for TR-PTSD, 3MDR could prove to be a valuable treatment option for military members and veterans with TR-PTSD.

The Role of Social Determinants of Health in Moral Injury: Implications and Future Directions

Purpose of Review

Exposure to potentially morally injurious events (PMIEs) and the development of moral injury have yet to be conceptualized as they relate to social determinants of health (SDoH).Recent Findings.In this paper, the extant literature on moral injury and SDoH is reviewed. Specific individual-level SDoH, including gender, sex, sexual orientation, race, and ethnicity, are explored relative to PMIEs and moral injury. The relationship among environmental SDoH, including childhood environment, justice involvement, and homelessness, is described.

Summary

Assessment and treatment implications are discussed, and future research directions highlighting the need for additional work addressing health inequities in moral injury are presented.

Treatment for Moral Injury: Impact of Killing in War

Purpose of Review

Veterans who kill in war are at risk of developing negative mental health problems including moral injury, PTSD, spiritual distress, and impairments in functioning. Impact of Killing (IOK) is a novel, cognitive-behaviorally based treatment designed to address the symptoms associated with killing that focuses on self-forgiveness and moral repair through cultivation of self-compassion and perspective-taking exercises, such as letter writing, and active participation in values-driven behavior.

Recent Findings

In a pilot trial assessing IOK, participants demonstrated a reduction in multiple mental health symptoms and improvement in quality-of-life measures, and they reported IOK was acceptable and feasible. Furthermore, trauma therapists have reported that moral injury is relevant to their clinical work, expressed a desire for additional training on the impact of killing, and identified barriers that make addressing killing in clinical settings challenging. Data are currently being collected in a national multi-site trial to examine the efficacy of IOK, compared to a control condition.

Summary

IOK fills a critical treatment gap by directly addressing the guilt, shame, self-sabotaging behaviors, functional difficulties, impaired self-forgiveness, and moral/spiritual distress directly associated with killing in war. Typically provided following some initial trauma-processing treatment, IOK can be integrated in existing systems of trauma care, creating a pathway for a stepped model of treatment for moral injury.

Research Gaps and Recommendations to Guide Research on Assessment, Prevention, and Treatment of Moral Injury Among Healthcare Workers

Healthcare workers face numerous occupational stressors, including some that may challenge personal and shared morals and values. This is particularly true during disasters and crises such as the COVID-19 pandemic, which require critical decisions to be made with little time and information often under personal distress and situational constraints. Consequently, healthcare workers are at risk for moral injuries characterized by stress-related and functional impacts. Although research on the evaluation and treatment of moral injury among military veterans burgeoned in the recent decade, addressing moral injury in healthcare workers and other civilians remains an important gap. In this perspective piece, we identify research gaps and make recommendations to advance future work on assessment, prevention, and treatment of moral injury in healthcare workers. We draw on empirical studies of moral injury in veterans, limited studies of moral injury in health professionals, and our clinical experiences with healthcare workers affected by moral injury.

Encountering children and child soldiers during military deployments: the impact and implications for moral injury

Background: During a deployment, soldiers must make seemingly impossible decisions, including having to engage with child soldiers. Such moral conflicts may continue to affect service members and veterans in the aftermath of a deployment, sometimes leading to severe moral distress, anguish, and personal crises. Service providers have increasingly argued that as a diagnosis, Post-Traumatic Stress Disorder (PTSD) cannot account for these deeply personal and painful moral conflicts. In light of this, the concept of moral injury has been introduced to better capture the profound forms of guilt and shame that may be experienced by service members and veterans. Objective: This paper addresses encounters with children and child soldiers during military deployments, as well as the risk for moral injury during and following these encounters, and their implications. This exploratory paper brings together existing literature on the topic to introduce, illustrate, and offer potential and promising interventions. Results: Given the potential moral conflicts that may ensue, military personnel who encounter child soldiers during a military deployment may be at risk for moral injury during and following these encounters. The introduction of the concept of moral injury provides a way for these largely unnamed personal and painful moral conflicts and violations to be recognized, addressed, and with appropriate care, remedied. Although there is limited research into their effectiveness at treating moral injury, individual and group-based interventions have been identified as potentially beneficial. Conclusion: As encounters with children during deployments are likely to continue, systematic research, training, healing interventions and prevention strategies are vital to support and protect children in conflict settings, as well as to ensure the mental health and well-being of service members and veterans. HIGHLIGHTS Profound moral conflicts may affect service members and veterans in the aftermath of a military deployment, sometimes leading to severe moral distress, anguish, and personal crises. The concept of moral injury has been introduced to better capture the profound forms of guilt and shame that may be experienced by service members and veterans.Encountering children and child soldiers during a military deployment, may present unique challenges, stress, and moral crises leading to potentially moral injurious events. In particular, transgression-based events which result from an individual perpetrating or engaging in acts that contravene his or her deeply held moral beliefs and expectations such as harming children, and betrayal-based events, which results from witnessing or falling victim to the perceived moral transgressions of others, may lead to lasting psychological, biological, spiritual, behavioural and social impairments.Interventions applied in both an individual-based context such as Cognitive Processing Therapy, Impact of Killing, Adaptive Disclosure, and a group-based context such as Acceptance and Commitment Therapy and Resilience Strength Training, have been identified as potentially beneficial to addressing moral injury. However, more research is required to ascertain appropriate and effective intervention and healing strategies.

Development of an online supportive treatment module for moral injury in military veterans and police officers

BACKGROUND

Military members and police officers often operate in high stakes situations and under high levels of physical and psychological stress. Consequently, they may be confronted with morally injurious experiences and develop moral injury. Most treatments for moral injury are cognitive-behavioral, face-to-face treatments, which may be supported by online interventions. Online interventions have shown promise in the treatment of trauma-related psychopathology, but few such interventions for moral injury yet exist.

OBJECTIVE

To develop and conduct a preliminary evaluation of an online treatment module for moral injury in treatment-seeking military veterans and police officers, to be used in conjunction with regular face-to-face treatment.

METHOD

An online module was developed based on the moral injury literature, using elements from seven existing treatments. A preliminary evaluation was conducted using both quantitative and qualitative methods, and focusing on perceived feasibility, acceptability and engagement of the module, as well as potential benefits and harms. The concept module was evaluated by 15 assessors, including patient representatives, multidisciplinary caregivers and experts.

RESULTS

The module was rated favorably, with mean evaluation scores ranging from 7.9 to 8.8 on a 10-point scale. Several suggestions for improvement were made, especially concerning privacy issues, safety instructions, patient-therapist collaborations, and role plays, and the module was adapted accordingly.

CONCLUSION

Using input from literature, patient representatives and experts, we developed an online treatment module for moral injury in military veterans and police officers, to be used in conjunction with face-to-face therapy. Acceptability and feasibility will be further examined in a future pilot study.

Association Between Responsibility for the Death of Others and Postdeployment Mental Health and Functioning in US Soldiers

IMPORTANCE

Rates of suicidal thoughts and behaviors (STBs) in US soldiers have increased sharply since the terrorist attacks on September 11, 2001, and postdeployment posttraumatic stress disorder (PTSD) remains a concern. Studies show that soldiers with greater combat exposure are at an increased risk for adverse mental health outcomes, but little research has been conducted on the specific exposure of responsibility for the death of others.

OBJECTIVE

To examine the association between responsibility for the death of others in combat and mental health outcomes among active-duty US Army personnel at 2 to 3 months and 8 to 9 months postdeployment.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study obtained data from a prospective 4-wave survey study of 3 US Army brigade combat teams that deployed to Afghanistan in 2012. The sample was restricted to soldiers with data at all 4 waves (1-2 months predeployment, and 2-3 weeks, 2-3 months, and 8-9 months postdeployment). Data analysis was performed from December 12, 2020, to April 23, 2021.

MAIN OUTCOMES AND MEASURES

Primary outcomes were past-30-day PTSD, major depressive episode, STBs, and functional impairment at 2 to 3 vs 8 to 9 months postdeployment. Combat exposures were assessed using a combat stress scale. The association of responsibility for the death of others during combat was tested using separate multivariable logistic regression models per outcome adjusted for age, sex, race and ethnicity, marital status, brigade combat team, predeployment lifetime internalizing and externalizing disorders, and combat stress severity.

RESULTS

A total of 4645 US soldiers (mean [SD] age, 26.27 [6.07] years; 4358 men [94.0%]) were included in this study. After returning from Afghanistan, 22.8% of soldiers (n = 1057) reported responsibility for the death of others in combat. This responsibility was not associated with any outcome at 2 to 3 months postdeployment (PTSD odds ratio [OR]: 1.23 [95% CI, 0.93-1.63]; P = .14; STB OR: 1.19 [95% CI, 0.84-1.68]; P = .33; major depressive episode OR: 1.03 [95% CI, 0.73-1.45]; P = .87; and functional impairment OR: 1.12 [95% CI, 0.94-1.34]; P = .19). However, responsibility was associated with increased risk for PTSD (OR, 1.42; 95% CI, 1.09-1.86; P = .01) and STBs (OR, 1.55; 95% CI, 1.03-2.33; P = .04) at 8 to 9 months postdeployment. Responsibility was not associated with major depressive episode (OR, 1.30; 95% CI, 0.93-1.81; P = .13) or functional impairment (OR, 1.13; 95% CI, 0.94-1.36; P = .19). When examining enemy combatant death only, the pattern of results was unchanged for PTSD (OR, 1.44; 95 CI%, 1.10-1.90; P = .009) and attenuated for STBs (OR, 1.46; 95 CI%, 0.97- 2.20; P = .07).

CONCLUSIONS AND RELEVANCE

This cohort study found an association between being responsible for the death of others in combat and PTSD and STB at 8 to 9 months, but not 2 to 3 months, postdeployment in active-duty soldiers. The results suggest that delivering early intervention to those who report such responsibility may mitigate the subsequent occurrence of PTSD and STBs.

COVID-19 related moral injury: Associations with pandemic-related perceived threat and risky and protective behaviors

BACKGROUND

The coronavirus-2019 (COVID-19) pandemic is associated with increased potential for morally injurious events, during which individuals may experience, witness, or learn about situations that violate deeply held moral beliefs. However, it is unknown how pandemic risk and resilience factors are associated with COVID-related moral injury.

METHODS

Individuals residing in the U.S. (N = 839; M_age = 37.09, SD = 11.06; 78% women; 63% White; 33% PTSD) participating in an online survey reported on COVID-19 related moral injury (modified Moral Injury Events Scale), perceived current and future threat of pandemic on life domains (social, financial, health), and COVID-19 risky and protective behaviors. Multivariate linear regressions examined associations of perceived threat and risky and protective behaviors on type of COVID-19 related moral injury (betrayal, transgression by others, self).

RESULTS

Participants endorsed MI betrayal (57%, N = 482), transgression by other (59%, N = 497), and by self 17% (N = 145). Adjusting for sociodemographics, only future threat of COVID-19 to health was significantly associated with betrayal (B = 0.21, p = .001) and transgression by other (B = 0.16, p = .01), but not by self. In contrast, high frequency of risky behaviors was associated with transgressions by self (B = 0.23, p < .001). Sensitivity analyses showed PTSD did not moderate the observed effects.

CONCLUSIONS

Betrayal and transgression by others was associated with greater perceived future threat of COVID-19 to health, but not financial or social domains. Stronger endorsement of transgression by self was associated with more frequently engaging in risky behaviors for contracting COVID-19. These findings may suggest the need for individual, community, and system level interventions to address COVID-19 related moral injury.

Patterns of distress associated with exposure to potentially morally injurious events among Canadian Armed Forces service members and Veterans: A multi-method analysis

OBJECTIVE

This study describes patterns of distress associated with exposure to potentially morally injurious experiences (PMIEs) in a Canadian military sample.

METHOD

Thematic analysis was performed on interviews from PMIE-exposed military members and Veterans. Participants also completed structured diagnostic interviews, and measures of trauma exposure and psychopathology. Multiple regression examined associations among these variables. Information on pharmacological treatment and past diagnoses are reported.

RESULTS

Eight qualitative themes were identified: changes in moral attitudes, increased sensitivity and reactivity to moral situations, loss of trust, disruptions in identity, disruptions in spirituality, disruptions in interpersonal relatedness, rumination, and internalizing and externalizing emotions and behaviors. Self-report data revealed that degree of PMIE exposure was meaningfully associated with posttraumatic stress disorder.

CONCLUSION

Qualitative but not quantitative findings supported existing models of moral injury (MI). Additional research is needed to examine the impact of PMIE type on mental health, and to test basic assumptions of MI theory.

Patterns of exposure to potentially morally injurious events among Israeli combat veterans: A latent class analysis approach

OBJECTIVE

Following exposure to events that transgress moral beliefs and expectations rooted in cultural, organizational, and group-based ethical rules, veterans can experience psychological, social, and spiritual problems referred to as Moral Injury (MI). We examined patterns of exposure to potentially morally injurious events (PMIEs) among Israeli veterans as well as psychological and functional correlates of exposure.

METHOD

A sample of 381 Israeli veterans volunteered to complete a cross-sectional electronic survey between 2017-2018. Latent Class Analysis (LCA) was used to identify classes characterized by unique patterns of exposure to PMIEs and compare differences in psychological and functional problems.

RESULTS

Three subgroups were identified: Moral Injury (12.1 %), Betrayal-Only (20.8 %), and Minimal Exposure (67.1 %). Whereas those in the betrayal-only class reported more traditional posttraumatic symptoms and those in the moral injury class reported more moral injury symptoms (i.e., guilt-related cognitions), some psychological problems were shared by veterans assigned to the moral injury and betrayal-only classes (e.g., entrapment). Importantly, while both those in the betrayal-only and moral injury classes had lower forgiveness relative to those in the minimal exposure class, those in the betrayal-only class received more familial support than did those in the moral injury class.

CONCLUSIONS

The study's findings offer an overview of the complex associations between patterns of exposure to PMIEs and associated outcomes. Clinicians treating veterans coping with combat trauma should be aware of the unique and shared symptoms reported by those with moral injury and betrayal exposures.

Compromised Conscience: A Scoping Review of Moral Injury Among Firefighters, Paramedics, and Police Officers

BACKGROUND

Public Safety Personnel (e.g., firefighters, paramedics, and police officers) are routinely exposed to human suffering and need to make quick, morally challenging decisions. Such decisions can affect their psychological wellbeing. Participating in or observing an event or situation that conflicts with personal values can potentially lead to the development of moral injury. Common stressors associated with moral injury include betrayal, inability to prevent death or harm, and ethical dilemmas. Potentially psychologically traumatic event exposures and post-traumatic stress disorder can be comorbid with moral injury; however, moral injury extends beyond fear to include spiritual, cognitive, emotional or existential struggles, which can produce feelings of severe shame, guilt, and anger.

OBJECTIVE

This scoping review was designed to identify the extant empirical research regarding the construct of moral injury, its associated constructs, and how it relates to moral distress in firefighters, paramedics, and police officers.

METHODS

A systematic literature search of peer-reviewed research was conducted using databases MEDLINE, EMBASE, APA PsychInfo, CINHAL PLUS, Web of Science, SCOPUS, and Google Scholar. Included studies were selected based on the inclusion criteria before being manually extracted and independently screened by two reviewers.

RESULTS

The initial database search returned 777 articles, 506 of which remained after removal of duplicates. Following review of titles, abstracts, and full texts, 32 studies were included in the current review. Participants in the articles were primarily police officers, with fewer articles focusing on paramedics and firefighters. There were two studies that included mixed populations (i.e., one study with police officers, firefighters, and other emergency service workers; one study with paramedic and firefighter incident commanders). Most studies were qualitative and focused on four topics: values, ethical decision-making, organizational betrayal, and spirituality.

CONCLUSION

Public safety organizations appear to recognize the experience of moral distress or moral injury among public safety personnel that results from disconnects between personal core values, formal and informal organizational values, vocational duties, and expectations. Further research is needed to better understand moral distress or moral injury specific to public safety personnel and inform training and treatment in support of public safety personnel mental health.

A contextual behavioral approach for responding to moral dilemmas in the age of COVID-19

Prior pandemics and current news stories suggest that a “second pandemic” of potentially devastating mental health consequences will follow the COVID-19 pandemic. Given the changing contextual demands associated with the pandemic for many people, the mental health consequences of COVID-19 are likely to include exposure to a range of moral dilemmas. Such dilemmas may set the stage for the development of moral distress and moral injury in a broad range of contexts from the ER to the grocery store. In the current paper we offer an approach to responding to moral dilemmas presented by COVID-19. We propose a contextual behavioral model of moral injury that is relevant to those experiencing moral pain associated with the COVID-19 pandemic. Based on this model, we offer two different approaches to intervening on COVID-19-related moral dilemmas. First, we propose the use of Acceptance and Commitment Therapy for Moral Injury (ACT-MI) among individuals suffering from moral injury. Second, to intervene on moral dilemmas at the level of the group, we propose the use of the Prosocial intervention. We offer case examples describing ACT-MI and Prosocial to highlight how these interventions might be applied to moral-dilemma-related concerns during the COVID-19 pandemic and discuss implications for future research.

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CBS can be applied to COVID-19-related moral distress and moral injury.

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ACT-MI may be used to intervene on COVID-19-related moral distress and injury.

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Prosocial may help groups respond to moral dilemmas and could prevent moral injury.

“That day no one spoke”: Florida Puerto Ricans’ Reaction to Hurricane María

We conducted two focus groups and four individual interviews to examine the experiences of Florida Puerto Rican adults ( N = 26) with secondary exposure to the devastation caused by Hurricane María. Results from our thematic analysis yielded four major themes and eight subthemes depicting responses to Hurricane María. Four major themes emerged across participant responses: 1) Participants’ Experience with Hurricane María, 2) Participants’ Negative Reactions to Hurricane María, 3) Participants Providing Support, and 4) Resilience and Growth. We also found that Florida Puerto Ricans’ secondary stress reactions were influenced by Puerto Rico’s political status and economic crisis. Results also indicated that participants experienced vicarious posttraumatic growth not only at the individual but also at the community level.

Defining and Measuring Moral Injury: Rationale, Design, and Preliminary Findings From the Moral Injury Outcome Scale Consortium

In the current paper, we first describe the rationale for and methodology employed by an international research consortium, the Moral Injury Outcome Scale (MIOS) Consortium, the aim of which is to develop and validate a content-valid measure of moral injury as a multidimensional outcome. The MIOS Consortium comprises researchers and clinicians who work with active duty military service members and veterans in the United States, the United Kingdom, the Netherlands, Australia, and Canada. We describe the multiphase psychometric development process being conducted by the Consortium, which will gather phenomenological data from service members, veterans, and clinicians to operationalize subdomains of impact and to generate content for a new measure of moral injury. Second, to illustrate the methodology being employed by the Consortium in the first phase of measure development, we present a small subset of preliminary results from semistructured interviews and questionnaires conducted with care providers (N = 26) at three of the 10 study sites. The themes derived from these initial preliminary clinician interviews suggest that exposure to potentially morally injurious events is associated with broad psychological/behavioral, social, and spiritual/existential impacts. The early findings also suggest that the outcomes associated with acts of commission or omission and events involving others' transgressions may overlap. These results will be combined with data derived from other clinicians, service members, and veterans to generate the MIOS.

Moral Injury: An Integrative Review

Individuals who are exposed to traumatic events that violate their moral values may experience severe distress and functional impairments known as "moral injuries." Over the last decade, moral injury has captured the attention of mental health care providers, spiritual and faith communities, media outlets, and the general public. Research about moral injury, especially among military personnel and veterans, has also proliferated. For this article, we reviewed scientific research about moral injury. We identified 116 relevant epidemiological and clinical studies. Epidemiological studies described a wide range of biological, psychological/behavioral, social, and religious/spiritual sequelae associated with exposure to potentially morally injurious events. Although a dearth of empirical clinical literature exists, some authors debated how moral injury might and might not respond to evidence-based treatments for posttraumatic stress disorder (PTSD) whereas others identified new treatment models to directly address moral repair. Limitations of the literature included variable definitions of potentially morally injurious events, the absence of a consensus definition and gold-standard measure of moral injury as an outcome, scant study of moral injury outside of military-related contexts, and clinical investigations limited by small sample sizes and unclear mechanisms of therapeutic effect. We conclude our review by summarizing lessons from the literature and offering recommendations for future research.

Spirituality and Moral Injury Among Military Personnel: A Mini-Review

Introduction: Moral injury (MI) results when military personnel are exposed to morally injurious events that conflict with their values and beliefs. Given the complexity of MI and its physical, emotional, social, and spiritual impact, a holistic approach is needed. While the biopsychosocial aspects of MI are more commonly addressed, less is known of the spiritual dimension and how to incorporate it into treatment that facilitates restoration of one's core self and mending of relationships with self, others, and the sacred/Transcendent. The purpose of this study was to gain a greater understanding of the relationship between spirituality/religion (S/R) and MI as experienced by military members and veterans and to consider how S/R might be better integrated into prevention and treatment strategies. Methods: A mini-review of peer-reviewed articles published between January 2000 and April 2018 regarding the relationship between spirituality and MI among military personnel and veterans was conducted. Results: Twenty-five articles were included in the final review. Five themes were identified and explored, including i) Spirituality: A potential cause of and protective factor against MI, ii) Self and identity: Lost and found, iii) Meaning-making: What once was and now is, iv) Spirituality as a facilitator of treatment for MI, and v) Faith communities: Possible sources of fragmentation or healing. Discussion: Findings identified a cyclical relationship between S/R and MI, whereby S/R can both mitigate and exacerbate MI, as well as be affected by it. Seen as a type of S/R struggle, the use of S/R-specific strategies [e.g., forgiveness, review of S/R beliefs, engagement in S/R practices, and (re)connection with S/R communities], integration of S/R perspectives into general interventions, and help from chaplains may support healing, self-regulation, and mending of relationships, moral emotions, and social connection. Further research is yet needed, however, regarding i) S/R orienting systems, interventions, practices, and rituals/ceremonies that might protect against and treat MI; ii) features of individuals who do/do not experience MI; iii) S/R assessment tools and interventions; and iv) ways to maximize the positive contributions of faith communities.

Provider perspectives on a novel moral injury treatment for veterans: Initial assessment of acceptability and feasibility of the Impact of Killing treatment materials

OBJECTIVE

We assessed whether treatment providers specializing in evidence-based treatment for posttraumatic stress disorder found the Impact of Killing (IOK), a novel treatment for moral injury among combat veterans, acceptable, and feasible.

METHODS

Ten providers from a large veterans administration (VA) medical center were provided with materials from IOK. We audio-recorded a semistructured interview with each provider where we elicited open-ended feedback as well as asked five structured questions about the relative advantage, compatibility, complexity/simplicity, trialability, and observability of IOK.

RESULTS

All providers found IOK feasible, acceptable, and something they could incorporate into their existing practice. Providers reported that the spiritual and moral concerns addressed in IOK were novel, and that self-forgiveness and making amends were critical components promoting healing from moral injury not emphasized in other treatments.

CONCLUSIONS

Among trauma providers, IOK was found acceptable and feasible, offering a novel approach to addressing moral injury among combat veterans.

Sources of moral injury among war veterans: A qualitative evaluation

OBJECTIVE

Service members deployed to war are at risk for moral injury, but the potential sources of moral injury are poorly understood. The aim of this qualitative study was to explore the types of events that veterans perceive as morally injurious and to use those events to develop a categorization scheme for combat-related morally injurious events.

METHOD

Six focus groups with US war veterans were conducted.

RESULTS

Analysis based on Grounded Theory yielded two categories (and eight subcategories) of events that putatively cause moral injury. The two categories were defined by the focal attribution of responsibility for the event: Personal Responsibility (veteran's reported distress is related to his own behavior) versus Responsibility of Others (veteran's distress is related to actions taken by others). Examples of each type of morally injurious event are provided.

CONCLUSIONS

Implications for the further development of the moral injury construct and treatment are discussed.

"Opening a Door to a New Life": The Role of Forgiveness in Healing From Moral Injury

For military veterans struggling with moral injury, forgiveness can become both an animating concern and a potential path to healing. In this perspective piece, we draw on our clinical work and research findings to examine why forgiveness matters to veterans who feel guilt and shame about their actions in war, what type of forgiveness is attainable and meaningful, and what role clinicians can play in facilitating forgiveness. We conclude by reflecting on the potential, as well as the limits and tensions, of forgiveness work in the context of military moral injury.

Spiritual Dimensions of Moral Injury: Contributions of Mental Health Chaplains in the Canadian Armed Forces

Moral Injury (MI) describes the profound distress experienced by military personnel as a result of a violation of personal beliefs. Impacting not only psychological, but spiritual, health, and well-being, MI is associated with spiritual/religious (S/R) suffering and a need to find hope, trust, connection, reconciliation, and wholeness. Addressing spiritual wounds can help military personnel overcome fundamental barriers that may impede them from effectively engaging in or benefitting from traditional trauma therapies and having a more complete recovery. Military Chaplains in the Canadian Armed Forces (CAF) are both embedded with the troops in garrison and theater and work closely with service providers such as the Royal Canadian Medical Services. In their role, they offer front-line support and services to members and their families and facilitate access to care. Specific to the assessment and treatment of MI, Mental Health Chaplains (MHCs) offer S/R expertise and a complimentary clinical skill set to service members and interdisciplinary teams. This perspectives article explores the S/R dimension of MI, discusses the role of MHCs in CAF Mental Health (MH) Clinics, and provides clinical perspectives of a MHC regarding the treatment of MI. Key focuses of MHC interventions include bridging to other mental health services and supports, facilitating S/R coping and grounding, reconciling worldviews, resolving anger at a God-figure (not specific to any S/R perspective) and fostering reconciliation. Based on the literature, Mental Health practitioner's feedback, and clinical experience, MHCs are integral to service provision regarding MI and warrant more widespread inclusion on interdisciplinary teams in CAF MH Clinics.