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

The Moral Injury Symptom Scale-Military Version (MISS-M) is a 45-item measure of moral injury (MI) symptoms designed to use in Veterans and Active Duty Military with PTSD. This paper reviews the psychometric properties of the MISS-M identified in a previous report, discusses the rationale for the development of the scale, and explores its possible clinical and research applications. The MISS-M consists of 10 theoretically grounded subscales that assess the psychological and spiritual/religious symptoms of MI: guilt, shame, betrayal, moral concerns, loss of meaning/purpose, difficulty forgiving, loss of trust, self-condemnation, spiritual/religious struggles, and loss of religious faith/hope. The scale has high internal reliability, high test-retest reliability, and a factor structure that can be replicated. The MISS-M correlates strongly with PTSD severity, depressive symptoms, and anxiety symptoms, indicating convergent validity, and is relatively weakly correlated with social, spiritual, and physical health constructs, suggesting discriminant validity. The MISS-M is the first multidimensional scale that measures both the psychological and spiritual/religious symptoms of MI and is a reliable and valid measure for assessing symptom severity in clinical practice and in conducting research that examines the efficacy of treatments for MI in Veterans and Active Duty Military personnel.

Invisible Moral Wounds of the COVID-19 Pandemic: Are We Experiencing Moral Injury?

Exposure to morally injurious events may have a severe, prolonged negative impact on psychosocial functioning, known as moral injury (MI). Research into the prevalence of MI has mostly focused on event exposure rather than on psychosocial impact. Also, the relationship between MI and post-traumatic stress disorder (PTSD) remains a matter of interest. The aim of this study was to identify MI and PTSD symptom profiles among trauma-exposed, treatment-seeking police officers and military veterans, and to explore demographic and clinical differences between symptom profiles. Latent class and multinomial regression analyses were conducted in a sample of 1,703 participants, using the Clinician-Administered PTSD Scale for DSM-5 and the Brief Symptom Inventory. Four classes of participants were identified, labeled as a MI class (n = 192; 11.27%), a MI-PTSD class (n = 565; 33.18%), a PTSD class (n = 644; 37.82%), and a Neither MI-nor PTSD class (n = 302; 17.73%), resulting in 44.45% (n = 757) of participants who met an MI symptom profile with or without PTSD. There were significant differences between the classes in terms of gender as well as PTSD and comorbid psychopathology symptom severity, the latter of which was highest in the MI-PTSD class. In conclusion, a substantial subgroup of trauma-exposed, treatment-seeking police officers and military veterans could be classified as suffering from MI. Routinely screening for MI in treatment-seeking police officers and military veterans is recommended, and interventions aimed at relieving MI in these populations may be indicated.

The Psychiatric Ramifications of Moral Injury Among Veterans

Traumatic social upheavals such as war actualise the need to investigate the interrelation between moral injury (MI) and post-traumatic stress disorder (PTSD), particularly in adolescence, a developmental period marked by heightened moral sensitivity and vulnerability. Although MI and PTSD are conceptually distinct, moral injury may contribute to the emergence or intensification of PTSD symptoms. This study examines the manifestation of MI and PTSD symptoms in young adults and analyses their narratives of war experience. The sample comprised 300 Ukrainian adolescents aged 18–26, screened using the PTSD Checklist for DSM-5 (PCL-5) and the Moral Injury Symptom Scale (MISS-M-SF). Based on screening results, three groups were identified: individuals with PTSD, individuals with pronounced MI without PTSD, and a non-diagnosed comparison group. Participants produced written narratives on the topic “My experience of living through war,” which were analysed using a narrative-psycholinguistic approach focusing on orientation, emotional valence, and narrative organization. The results demonstrate statistically significant differences in MI symptom profiles between respondents with and without PTSD, as well as meaningful correlations between PTSD symptom clusters and specific MI components, including moral conflict, shame, self-condemnation, and loss of meaning. Narrative analysis revealed predominantly negative orientations toward traumatic experience across groups, alongside differences in behavioural strategies, emotional focus, and the balance between individual and collective experience. Narratives of participants with PTSD showed extensive detailing of traumatic events and active coping strategies, whereas narratives of participants with MI without PTSD were characterised by ambivalence and social withdrawal. The findings underscore the close relationship between MI and PTSD in adolescence and highlight the diagnostic and therapeutic value of narrative analysis in understanding trauma-related experiences. Disclosure Statement The authors reported no potential conflict of interests.

Military service may place veterans at increased risk for perpetrating, witnessing, or failing to prevent events that violate deeply held moral values. In some cases, veterans may develop moral injury (MI) symptoms that transcend and/or overlap with mental health conditions such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). Further, PTSD and MDD are 2 established risk factors for chronic pain. However, research has not examined the association between MI symptoms and chronic pain. We tested whether MI would emerge as a salient correlate of concurrent reports of chronic pain in the presence of PTSD and MDD symptom severity among 59 veterans seeking integrated behavioral health care. Findings indicated the severity of MI symptoms was significantly linked with veterans' concurrent reports of chronic pain. Self-directed MI symptoms emerged as a correlate of worse pain in the presence of PTSD and MDD. Preliminary findings demonstrate possible associations between MI and chronic pain among veterans with a need for holistic health care. Future research should examine mechanisms for an apparent MI-chronic pain link. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

PurposeThis study is a scoping literature review of research into post-traumatic stress disorder (PTSD) and moral injury (MI) in active-duty military personnel and veterans in Ukraine. This study aims to explore the existing research regarding the relationship between PTSD and MI in Ukrainian military personnel to identify the need for future research in a vulnerable social group that is exposed to a high level of conflict.Design/methodology/approachThis scoping review includes the results of peer-reviewed articles from online databases (PubMed, Science Direct, PsycArticles, Military Database, Sociological , Psychology Database, PTSD Pubs, Web of Science), which were searched for publications in English, Ukrainian and Russian. The data obtained was organized using Preferred Reporting Items for Systematic Reviews extension for scoping reviews and Meta-Analyses, the Critical Appraisal Skills Programme Qualitative Studies Checklist and Joanna Briggs Institute Critical Appraisal Checklist. Data was analyzed and categorized using an inductive thematic analysis.FindingsAccording to the thematic analysis, the following themes were identified in a Ukrainian military context: sources of PTSD, sources of moral injury, symptoms of PTSD, symptoms of moral injury and treating and prevention mechanisms. All studies included in the scoping review (32) report on PTSD and/or MI in military groups in Ukraine. They find the gap in research and in numerous comprehensive studies problematic and underline the need for more effective rehabilitation programs.Practical implicationsA scoping review was conducted to thematically map the research in the area, identify any knowledge gaps deficit about PTSD and MI in Military personnel in Ukraine and contribute to further development of effective rehabilitation programs.Originality/valueThe sparsity of the existing literature highlights the need for further research into enhancing the mental health services provided to military personnel. In addition, there is a growing need to further explore trauma exposure and potentially morally injurious events related to PTSD and MI, in particular. Such a review has not yet been carried out, which adds value to the current paper.

Moral injury: the effect on mental health and implications for treatment

Moral Injury (MI) and Posttraumatic Stress Disorder (PTSD) are potential outcomes following combat military service which exposes veterans to a range of potentially morally injurious events (PMIEs). Given the hypothesized social nature of MI symptoms, it was predicted that System Justification, the tendency to defend and justify systems, even when they may be disadvantageous, would be uniquely related to MI, compared to PTSD. A total of 146 male combat veterans filled in questionnaires relating to PMIEs (MIES), MI (EMIS-short), PTSD symptoms (PCL-5) and System Justification (GSJS). PMIEs (self, other and betrayal related) were all related to higher levels of MI. A parallel mediation model was conducted and demonstrated that PMIEs (self) were associated with higher levels of MI and PTSD symptoms and that MI symptoms mediated the relationship between PMIEs (self) and lower System Justification. There was no mediation effect of PTSD symptoms. This relationship was strongest when veterans did not perform reserve duty and thus were not affiliated with the military. The findings support the theory that MI symptomology, as opposed to PTSD symptomology, has a greater relationship with worldviews such as the relationship to societal systems and that this is greatest when transitioned to civilian life.

There is growing evidence that moral injury (MI) is related to greater suicide risk among Veterans and Active Duty Military (V/ADM). This study examines the relationship between MI and suicide risk and the moderating effect of religiosity on this relationship in V/ADM with post-traumatic stress disorder (PTSD) symptoms. This was a cross-sectional multi-site study involving 570 V/ADM from across the USA. Inclusion criteria were having served in a combat theater and the presence of PTSD symptoms. Multidimensional measures assessed MI, religiosity, PTSD symptoms, anxiety, and depression. In this secondary data analysis, a suicide risk index was created based on 10 known risk factors. Associations between MI and the suicide risk index were examined, controlling for demographic, religious, and military characteristics, and the moderating effects of religiosity were explored. MI overall was correlated strongly with suicide risk (r = 0.54), as were MI subscales (ranging from r = 0.19 for loss of trust to 0.48 for self-condemnation). Controlling for other characteristics had little effect on this relationship (B = 0.016, SE = 0.001, p < 0.0001). Religiosity was unrelated to suicide risk and did not moderate the relationship between suicide risk and MI or any of its subscales. MI is strongly and independently associated with risk factors for suicide among V/ADM with PTSD symptoms, and religiosity does not mediate or moderate this relationship. Whether interventions that target MI reduce risk of suicide or suicidal ideation remains unknown and needs further study.

Exposure to potentially morally injurious events (PMIEs) during military service is associated with mental health problems. However, knowledge about these associations and possible mechanisms of effect among female combat veterans is sparse. This study examines associations between PMIEs, posttraumatic stress disorder (PTSD), complex PTSD, depression and anxiety symptoms among female veterans, as well as the mediating role of disruption in assumptive world and moral injury (MI) symptoms. A volunteer sample of Israeli female combat veterans (n=885) and non-combat veterans (n=728) responded to self-report questionnaires in a cross-sectional design study. Results show that combat veterans reported higher levels of PMIEs, PTSD and MI symptoms, but not CPTSD, depression and anxiety symptoms, as compared to non-combat veterans. Importantly, PMIEs was indirectly associated with PTSD, complex PTSD, depression and anxiety symptoms through serial mediators of disruption in assumptive world and MI symptoms. This study emphasized the exposure to PMIEs and its posttraumatic sequelae among female combat veterans as compared to non-combat veterans. Our findings also suggest that future longitudinal studies should examine the mediating role of disruption in assumptive world and MI symptoms for the deleterious effects of exposure to PMIEs during military service.

The purpose of this study was to develop a multi-dimensional measure of moral injury symptoms that can be used as a primary outcome measure in intervention studies that target moral injury (MI) in Veterans and Active Duty Military with PTSD. This was a multi-center study of 427 Veterans and Active Duty Military with PTSD symptoms recruited from VA Medical Centers in Augusta, Los Angeles, Durham, Houston, and San Antonio, and from Liberty University in Lynchburg. Internal reliability of the Moral Injury Symptom Scale-Military Version (MISS-M) was examined along with factor analytic, discriminant, and convergent validity. Participants were randomly split into two equal samples, with exploratory factor analysis conducted in the first sample and confirmatory factor analysis in the second. Test-retest reliability was assessed in a subsample of 64 Veterans. The 45-item MISS-M consists of 10 theoretically grounded subscales assessing guilt, shame, moral concerns, religious struggles, loss of religious faith/hope, loss of meaning/purpose, difficulty forgiving, loss of trust, and self-condemnation. The Cronbach's alpha of the overall scale was .92 and of individual subscales ranged from .56 to .91. The test-retest reliability was .91 for the total scale and ranged from .78 to .90 for subscales. Discriminant validity was demonstrated by relativelyweak correlations with other psychosocial, religious, and physical health constructs, and convergent validitywas indicated by strong correlations with PTSD, depression, and anxiety symptoms. The MISS-M is a reliable and valid multi-dimensional symptom measure of moral injury that can be used in studies targeting MI in Veterans and Active Duty Military with PTSD symptoms and may also be used by clinicians to identify those at risk.

We examined Veterans' perspectives on discussing moral injury in veterans affairs (VA) evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD) and other VA treatment. Fourteen male warzone veterans (ages 25-74) who completed an EBP for PTSD within the past year participated in semistructured interviews related to discussing moral injury in VA treatment (e.g., EBPs for PTSD, chaplaincy). Qualitative interviews were evaluated using a thematic analysis. Four themes were identified; moral injury is often not identified or discussed during therapy, therapeutic relationships can promote or inhibit discussion of moral injury, treatment has limited impact on moral injury, and it is difficult to cope with moral injury even after treatment. The majority of Veterans interviewed identified moral injury persisting within a year of completing a PTSD EBP. These findings highlight the value of asking about, assessing, and treating moral injury in Veterans. Our results suggest the importance of developing specific moral injury interventions for warzone Veterans.

Mindfulness-based approaches have been suggested as possible methods to treat moral injury in military personnel. However, empirical research has yet to evaluate if mindfulness acts as a protective factor for the possible negative effects of moral injury, such as alcohol use, drug use, or posttraumatic stress disorder (PTSD) symptoms. In this study, we investigated if five facets of mindfulness (i.e., observing, nonjudging, nonreactivity, awareness, and describing) moderated associations between moral injury and the outcomes of PTSD symptoms, alcohol misuse, and drug abuse symptoms in a sample of military personnel. Participants were 244 military personnel (the majority were former military members) who had been deployed at least once during the Iraq War, War in Afghanistan, other wars, or humanitarian missions. The study results indicated that nonjudging, β = -.22, and awareness, β = -.25, had significant attenuating effects on the association between moral injury and drug abuse symptoms. However, observing, β = .17; nonreactivity, β = .23; and describing, β = .15, had significant synergistic effects (i.e., they strengthened the association between moral injury and drug abuse symptoms). There were no significant moderation effects on the associations between moral injury and PTSD symptoms or between moral injury and alcohol misuse. Our results provide initial evidence that not all facets of mindfulness may protect against the challenges of coping with moral injury. Directions for future research and implications for practice are discussed.

During the COVID-19 pandemic, health and social care workers (HSCWs) are facing morally challenging situations and life-threatening decisions. Following exposure to potentially morally injurious events (PMIEs) that undermine deeply held moral beliefs and expectations, HSCWs might experience moral injury (MI) and other deleterious psychiatric consequences. The present study examined associations between exposure to PMIEs, MI symptoms, posttraumatic stress disorder (PTSD), complex PTSD (CPTSD), and self-criticism among HSCWs. A sample of 296 Israeli HSCWs responded to online validated self-report questionnaires in a cross-sectional designed survey in February and March 2021. Participants' self-reported PTSD (8.9%) and CPTSD (4.8%) rates match the rates of Israel's general population. A moderated-mediation model shows that high self-criticism intensified the relations between exposure to PMIEs and MI symptoms, and between MI symptoms and CPTSD symptoms. Importantly, the indirect effect of exposure to PMIEs on both PTSD and CPTSD symptoms via MI symptoms existed only among those with high levels of self-criticism. The study's findings offer a novel overview of the associations between patterns of exposure to PMIEs, MI, PTSD, and CPTSD. Clinicians treating HSCWs coping with COVID-19-related moral injury should be aware of the importance of high self-criticism in the possible posttraumatic sequelae of exposure to PMIEs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).