Commentary on the Special Issue on Moral Injury: Advances, Gaps in Literature, and Future Directions.

Abstract

We contextualize and provide commentary on articles in the current issue that address the nature, measurement, and consequences of exposure to potentially morally injurious events (PMIEs) and moral injury (MI). PMIEs involve acts of commission or omission of oneself and others and can include perpetration of, and failure to prevent, harm; MI includes "the lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations" (Litz etal., 2009). New and informative research aims to characterize types of PMIEs among military service members and veterans, including in multinational samples. There are also ongoing efforts to devise outcome scales that reliably capture broad MI outcome themes. Further, several new measures of MI assess emotional, cognitive, and behavioral responses of wrong-doing; the nature of distress following PMIEs in civilians, servicemembers, and veterans; and interpersonal consequences in youth. These are promising efforts toward ecologically valid definitions of a potential MI phenotype. Notably, PMIEs may or may not meet DSM PTSD Criterion A, yet early longitudinal data reveal predictive and reciprocal effects of MI and PTSD on one another. Further, a growing literature on MI outcomes beyond PTSD is identifying ways in which MI is linked to alcohol misuse and self-injurious behaviors. The sum of these efforts has led experts to consider the utility and shortcomings of extant PTSD interventions for individuals with MI. We address clinical implications of this emerging research domain, gaps in the literature, and future directions for research.