Assessment of Moral Injury in Veterans and Active Duty Military Personnel With PTSD: A Review.

Harold G Koenig,Nagy A Youssef,Michelle Pearce

doi:10.3389/fpsyt.2019.00443

Abstract

Background: Moral injury (MI) involves distress over having transgressed or violated core moral boundaries, accompanied by feelings of guilt, shame, self-condemnation, loss of trust, loss of meaning, and spiritual struggles. MI is often found in Veterans and Active Duty Military personnel with posttraumatic stress disorder (PTSD). MI is widespread among those with PTSD symptoms, adversely affects mental health, and may increase risk of suicide; however, MI is often ignored and neglected by mental health professionals who focus their attention on PTSD only. Methods: A review of the literature between 1980 and 2018 conducted in 2018 is presented here to identify scales used to assess MI. Databases used in this review were PsychInfo, PubMed (Medline), and Google Scholar. Search terms were “moral injury,” “measuring,” “screening,” “Veterans,” and “Active Duty Military.” Inclusion criteria were quantitative measurement of MI and health outcomes, Veteran or Active Duty Military status, and peer-review publication. Excluded were literature reviews, dissertations, book chapters, case reports, and qualitative studies. Results: Of the 730 studies identified, most did not meet eligibility criteria, leaving 118 full text articles that were reviewed, of which 42 did not meet eligibility criteria. Of the remaining 76 studies, 34 were duplicates leaving 42 studies, most published in 2013 or later. Of 22 studies that assessed MI, five used scales assessing multiple dimensions, and 17 assessed only one or two aspects (e.g., guilt, shame, or forgiveness). The remaining 20 studies used one of the scales reported in the first 22. Of the five scales assessing multiple dimensions of MI, two assess both morally injurious events and symptoms and the remaining three assess symptoms only. All studies were cross-sectional, except three that tested interventions. Conclusions: MI in the military setting is widespread and associated with PTSD symptom severity, anxiety, depression, and risk of suicide in current or former military personnel. Numerous measures exist to assess various dimensions of MI, including five multidimensional scales, although future research is needed to identify cutoff scores and clinically significant change scores. Three multidimensional measures assess MI symptoms alone (not events) and may be useful for determining if treatments directed at MI may both reduce symptoms and impact other mental health outcomes including PTSD.

Highlights

RationaleExperiences during combat have long been known to cause internal moral or ethical conflicts [1]
This review focused on scales that assess single or only a few dimensions of Moral injury” (MI) and those that more comprehensively assess multiple aspects of this construct
The search term “moral injury” alone identified 62 articles in PubMed and 160 articles in PsychInfo, which represented the total number of articles identified by the three reviewers

Summary

Introduction

RationaleExperiences during combat have long been known to cause internal moral or ethical conflicts [1]. MI acquired during combat has been described as “a deep sense of transgression including feelings of shame, grief, meaninglessness, and remorse from having violated core moral beliefs” (p xiv, Brock & Lettini) [5], including “a betrayal of what’s right, by someone who holds legitimate authority, in a high-stakes situation” (Shay, p 183) [6]. Such feelings relate to what one has done (killed combatants or innocents, dismembered bodies, maltreated others, or deserted comrades during battle), what one has failed to do (protected innocents or prevented the death of fellow soldiers), or what one has observed others do or fail to do. MI is widespread among those with PTSD symptoms, adversely affects mental health, and may increase risk of suicide; MI is often ignored and neglected by mental health professionals who focus their attention on PTSD only

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