Moral Injury Events Scale Research Articles

Occupational Health of Animal Shelter Employees by Live Release Rate, Shelter Type, and Euthanasia-Related Decision

ABSTRACTApproximately a quarter of dogs and cats in animal shelters in the United States are euthanized. The stress associated with having to care for animals they subsequently euthanize puts animal shelter workers at a high risk for compassion fatigue, burnout, and even suicide. The aim of the present study was to assess the relationship between a shelter’s Live Release Rate (LRR; defined as the percent of animals that leave the animal shelter with a positive outcome) and the involvement in euthanasia-related decision-making on employees’ mental health. An online nationwide survey was administered to 153 municipal and private shelter workers consisting of the Impact of Event Scale-Revised, the Professional Quality of Life Questionnaire, the Moral Injury Event Scale, and questions relating to their work environment. A multivariate regression model found that compassion satisfaction (p < 0.00001), secondary traumatic stress (p = 0.008), moral injury (p = 0.037), and burnout (p = 0.002) were positively correlated with LRR. This suggests that although job satisfaction is greater in shelters with more positive outcomes, trauma may also be greater. A t-test revealed that employees who euthanize have higher moral injury scores compared with those who do not (t(152) = –2.96, p = 0.0036). A second multivariate regression model found that deciding which animal to euthanize predicted increased secondary traumatic stress (r(151) = –0.058, p = 0.016). Overall, the data show that LRR and decisions surrounding euthanasia play a role in occupational trauma; furthermore, the data provide support for further exploration of moral injury in animal shelter workers.

Examining the Factor Structure of the Moral Injury Events Scale in a Veteran Sample.

Interest in moral injury has burgeoned over the last decade as an increasing number of professionals recognize that current conceptualizations of trauma are not sufficient to explain some of the challenges that military service members face. The Moral Injury Events Scale (MIES) was the first instrument developed to measure exposure to military events that could produce moral injury (Nash et al., 2013). Two previously published validation studies that focused on service members still in uniform reveal some discrepancies regarding the scale's factor structure. Bryan and colleagues (2016) documented a three-factor solution (i.e., transgressions-others, transgressions-self, and betrayal), while Nash and colleagues (2013) noted a two-factor solution (i.e., perceived transgressions and perceived betrayals). With an interest in further scale validation, the present study utilized survey data from a group of veterans recently separated from service, to test the fitness of the two- or three-factor model and to examine the invariance of the scale across gender and branch. The investigators followed the policies governing the protection of human subjects as prescribed by ICF Institutional Review Board. Findings revealed a two-factor structure that differed from previous factor solutions (transgressions-self and transgressions-others) and was invariant across gender and branch. High intercorrelations among the MIES items that addressed exposure and reaction to events suggested that these experiences tend to co-occur. Removal of the event items did not significantly impact model fit. The factor structure identified in the present study aligns with current theoretical conceptualizations of moral injury. The inability to distinguish between event and reaction items and the lack of impact on the factor structure when event items were removed from the model suggest the MIES is more accurately described as a measure of moral pain as compared to a measure of potentially morally injurious experiences (PMIEs). Given that all events associated with moral injury have impinged upon welfare, justice, rights, and fairness considerations, one could argue that little would be gained by focusing attention on the development of a measure of PMIEs. Given the lack of convergence in factor structure across samples, future directions may profit from a focus on further clarifying the temporal stability of the MIES factor structure.

Intolerance of Uncertainty Moderates the Association Between Potentially Morally Injurious Events and Suicide Ideation and Behavior Among Combat Veterans.

Exposure to potentially morally injurious events (PMIEs) among combat veterans has been acknowledged as significant stressful combat events that may lead to mental health problems, including self-injurious thoughts and behavior (SITB). However, few studies have examined the risk and protective factors that can explain the conditions in which PMIEs may contribute to the development and maintenance of SITB. In the current study, we aimed to examine the association between PMIEs and SITB among combat veterans and explore the moderating roles of intolerance of uncertainty (IU) in this association. A volunteer sample of 191 Israeli combat veterans was recruited during 2017. Participants completed validated self-report questionnaires in a cross-sectional study. Results indicated that two separate measures of PMIEs, the Perceived Perpetration by Oneself and Others subscale of the Moral Injury Events Scale (MIES) and the Causes subscale of the Moral Injury Questionnaire (MIQ-Causes), were positively associated with higher levels of SITB. Moreover, beyond the contributions of reserve duty, posttraumatic stress symptoms, and depressive symptoms, MIQ-Causes scores significantly predicted current SITB. Importantly, under low and average levels of inhibitory IU, significant positive effects were revealed for the MIQ-Causes on current SITB, R² = .34. Although veterans exposed to PMIEs are more prone to SITB, even years after their release from military service, their IU may temper the link between experiences of PMIEs and SITB.

Resting‐state brain fluctuation and functional connectivity dissociate moral injury from posttraumatic stress disorder

Moral injury is closely associated with posttraumatic stress disorder (PTSD) and characterized by disturbances in social and moral cognition. Little is known about the neural underpinnings of moral injury, and whether the neural correlates are different between moral injury and PTSD. A sample of 26 U.S. military veterans (two females: 28-55 years old) were investigated to determine how subjective appraisals of morally injurious events measured by Moral Injury Event Scale (MIES) and PTSD symptoms are differentially related to spontaneous fluctuations indexed by amplitude of low frequency fluctuation (ALFF) as well as functional connectivity during resting-state functional magnetic resonance imaging scanning. ALFF in the left inferior parietal lobule (L-IPL) was positively associated with MIES subscores of transgressions, negatively associated with subscores of betrayals, and not related with PTSD symptoms. Moreover, functional connectivity between the L-IPL and bilateral precuneus was positively related with PTSD symptoms and negatively related with MIES total scores. Our results provide the first evidence that morally injurious events and PTSD symptoms have dissociable neural underpinnings, and behaviorally distinct subcomponents of morally injurious events are different in neural responses. The findings increase our knowledge of the neural distinctions between moral injury and PTSD and may contribute to developing nosology and interventions for military veterans afflicted by moral injury.

The relation between adverse childhood experiences and moral injury in the Canadian Armed Forces

ABSTRACT Background: There is increasing evidence that moral injuries (MIs) may affect the mental health of Canadian Armed Forces (CAF) members and veterans. Despite knowledge suggesting that MIs are related to multiple negative mental health outcomes, including the onset of post-traumatic stress disorder (PTSD), it is unknown whether pre-traumatic variables, including the presence of childhood abuse, are related to MIs. Objective: This study seeks to investigate the potential relationship between adverse childhood experiences and later onset MI in military members. Methods: Thirty-three patients newly admitted to an inpatient unit for treatment of trauma-related disorders received a standardized self-assessment package, including the PTSD Checklist for DSM-5 (PCL-5), the Moral Injury Events Scale (MIES; adapted for the Canadian context), and the Adverse Childhood Experiences Questionnaire (ACE-Q), which is a retrospective measure of childhood abuse. Results: Analyses revealed a significant relation between childhood emotional abuse and the presence of MI in adulthood. Specifically, emotional abuse during childhood was correlated with total score on the MIES (p = 0.006) and with its two subscales, perceived betrayals (p = 0.022) and perceived transgressions (p = 0.016). These correlations remained significant when controlling for age and gender. Conclusions: Among CAF members and veterans, childhood events are related to the presence of MI during adulthood. These preliminary data are provocative in suggesting that emotional abuse during childhood may increase the likelihood of endorsing MI during adult military service. Further work is needed to identify pre-traumatic variables that may serve to increase risk or enhance resilience to the development of MI in military members.

A Preliminary Study Examining the Prevalence and Perceived Intensity of Morally Injurious Events in a Veterans Affairs Chaplaincy Spiritual Injury Support Group

The aim of this descriptive study was to examine the prevalence and perceived intensity of potentially morally injurious events (PMIEs) in a group of VA chaplaincy service users. A secondary aim was to examine the relationship between PMIEs, spiritual injury, and religiosity. A convenience sample of veterans (n = 84), participants in a spiritual injury support group, completed the Moral Injury Events Scale (MIES). Most individuals also completed the Duke University Religion Index (as a measure of religiosity) and Spiritual Injury Scale. Results suggest a high prevalence of PMIEs among participants. These PMIEs were also higher in perceived intensity compared to other military and veteran samples. No significant correlations were identified between MIES scores and either religiosity or spiritual injury. These findings draw attention to the engagement of chaplains in supporting veterans affected by PMIEs. Implications for future research are discussed.

Measures of morally injurious experiences: A quantitative comparison

A recent body of literature has examined the psychological effects of perpetrating or failing to prevent acts that violate one's sense of right and wrong. The objective of this study was to examine and compare correlations between the two most widely used instruments measuring this construct in a sample of military veterans and relevant psychosocial variables. Individuals (N = 182) who reported military combat experience completed the Moral Injury Events Scale and the Moral Injury Questionnaire-Military Version, along with measures of combat exposure, depression, posttraumatic stress disorder, alcohol concerns, anger, guilt, and shame. Results indicate similar correlations between the morally injurious experiences instruments and negative psychosocial variables, but different correlations with combat exposure. Implications for further research in the conceptualization and treatment of morally injurious experiences are discussed.

TRR's Warrior Camp: An Intensive Treatment Program for Combat Trauma in Active Military and Veterans of All Eras.

Effective treatments for combat trauma in military service members exist, but barriers to care abound, including poor access, stigma, and dropout. Although the effects of post-traumatic stress disorder (PTSD) can be severe, recovery is possible when proper treatment is implemented. Trauma and Resiliency Resources, Inc.'s Warrior Camp (WC) program is designed to address the effects of combat trauma in military service members and veterans. This intensive, 7-d treatment incorporates eye movement desensitization and reprocessing therapy, equine-assisted psychotherapy, yoga, and narrative writing in context of community. This single-group pretest-posttest design included paired t-tests and effect size analyses for 85 participants of WC. Outcome measures included the Mississippi Scale for Combat-related PTSD, the Patient Health Questionnaire, the Revised Adult Attachment Scales, and the Moral Injury Events Scale. Clinician-administered measures included the Davidson Trauma Scale and the Dissociative Experiences Scale. All measures showed statistically significant reductions in distress. The effect sizes ranged from small to large. Results suggest that WC participants experienced significant improvement in PTSD, depression, moral injury, dissociation and adult attachment. Clinicians should consider the potential benefits of this short-term, intensive treatment when addressing combat-related PTSD among military service members and veterans.

“Basically, I look at it like combat”: Reflections on moral injury by parents involved with child protection services

This study considers any “moral injury” occurring among parents involved with the Child Protection System (CPS). Moral injury refers to the lasting psychological, spiritual and social harm caused by one's own or another's actions in a high stakes situation that transgress deeply held moral beliefs and expectations. The existing literature focuses on military contexts, but moral injury also may play a role in increasing the vulnerability of CPS clients who are threatened with loss of their parental rights and dissolution of their families. We administered a modified version of the Moral Injury Events Scale (MIES) (Nash et al., 2013) to 10 CPS involved parents. We then conducted in-depth, semi-structured, audio recorded individual interviews with parents to elaborate their responses to the MIES. Parents' MIES scores and interview elaborations suggest that some CPS-involved parents do experience moral injury. Moral injury was reported as a result of their own parenting behaviors, but also as a result of parents' involvement with professionals and within social systems that are charged with providing assistance to struggling families. For instance, some parents perceived professionals to be shaming, social services to be harmful and legal proceedings stigmatizing. Parents' reported reactions to morally injurious events included lasting feelings of guilt, shame and anger; and loss of trust in professionals. These responses impeded their perceived abilities to fully engage in services. If involvement in CPS places parents at increased risk of moral injury, then moral injury is a critically important construct for child welfare policy makers and workers to understand and address in the conduct of effective, ethical child welfare practice.

Everyday coping with moral injury: The perspectives of professionals and parents involved with child protection services

This study examines how Child Protection Services (CPS) – involved parents and professionals describe coping with moral injury through resources available within their everyday lives. Moral injury refers to the lasting harm caused by one's own or another's actions in high-stakes situations that transgress deeply held moral beliefs and expectations. This harm can occur at multiple, interacting psychological, social and spiritual levels. We administered a modified version of the Moral Injury Events Scale (MIES) (Nash et al., 2013) to 38 CPS-involved professionals and 10 parents. We then conducted in-depth, semi-structured, audio-recorded individual interviews with them to elaborate their responses to the MIES, and reflect on scenarios involving moral injury. For the current study we analyzed the responses of those in the sample who reported moral injury (eight CPS-involved parents and 35 professionals.) None had received professional support to address their moral injury. Participants' described coping with moral injury through a variety of resources available in their everyday lives. Their coping strategies reflected multiple, interacting levels of the ecology. Participants contributed vivid and detailed accounts of coping through drawing upon and strengthening their: (a) psychological resources through stress reducing and meaning-making activities, mental toughness, agency, acceptance, strong values, self-reflection and forgiveness; (b) microsystems through social support and corrective experiences; (c) macrosystems through engagement in advocacy and social programs to support other parents; and (d) spiritual engagement. Our aim is to identify potential models of successful coping with moral injury in everyday life in order to identify viable targets for formal prevention and intervention efforts.

Moral injury among Child Protection Professionals: Implications for the ethical treatment and retention of workers

This study considers any “moral injury” occurring among professionals working within the Child Protection System (CPS). Moral injury refers to the lasting psychological, spiritual and social harm caused by one's own or another's actions in high-stakes situations that transgress deeply held moral beliefs and expectations. We administered a modified version of the Moral Injury Events Scale (MIES) (Nash et al., 2013) to 38 CPS professionals. We then conducted in-depth, semi-structured, audio-recorded individual interviews with them to elaborate their responses to the MIES. Professionals' MIES scores and descriptions of their responses suggest that some professionals do experience moral injury as a result of their CPS involvement. Similar to parents involved with CPS, professionals described harm to themselves occurring through under-resourced systems, problematic professionals, unfair laws and policies, abusive parents, an adversarial system, systemic biases, harm to children by the system and poor-quality services. They also communicated feelings associated with moral injury such as anger and sadness, emotional numbing, and guilt and shame. These feelings have been reported by CPS-involved parents and are described in the existing moral injury literature. Many also described troubling, existential issues including their ability to function in an ethical and moral manner within a system they viewed as deeply flawed, and in an unsupportive working environment steeped in human misery. Nearly a third of all professionals described themselves or colleagues as actively seeking employment elsewhere. We discuss implications for the related issues of the ethical treatment and retention of professionals working within CPS.

The Impact of Aggression on the Relationship Between Betrayal and Belongingness Among U.S. Military Personnel

The suicide rate among U.S. military personnel, particularly within the Army National Guard, is significantly higher than the rate found among the general population. To better understand why the Army National Guard has elevated rates of suicide, the current study examined how deployment-related moral injury interacts with interpersonal factors to predict suicide risk. Specifically, this study hypothesized that deployment-related betrayal, a facet of the Moral Injury Events Scale, would predict thwarted belongingness and that this relationship would be moderated by several types of aggression (physical aggression, verbal aggression, hostility, and anger). The current sample comprised 562 military personnel who had experienced at least 1 previous deployment. Results revealed that betrayal predicted thwarted belongingness in the presence of high but not low or mean levels of aggression among military personnel. This indicates that aggressive individuals who experience perceived betrayal while deployed may be at high risk for development of thwarted belongingness, an important risk factor for suicide. These results suggest the need for better assessment and treatment of betrayal among military personnel, as well as the need for programs to help soldiers manage aggression.

Moral injury in U.S. combat veterans: Results from the national health and resilience in veterans study.

Combat exposure is associated with increased risk of mental disorders and suicidality. Moral injury, or persistent effects of perpetrating or witnessing acts that violate one's moral code, may contribute to mental health problems following military service. The pervasiveness of potentially morally injurious events (PMIEs) among U.S. combat veterans, and what factors are associated with PMIEs in this population remains unknown. Data were analyzed from the National Health and Resilience in Veterans Study (NHRVS), a contemporary and nationally representative survey of a population-based sample of U.S. veterans, including 564 combat veterans, collected September-October 2013. Types of PMIEs (transgressions by self, transgressions by others, and betrayal) were assessed using the Moral Injury Events Scale. Psychiatric and functional outcomes were assessed using established measures. A total of 10.8% of combat veterans acknowledged transgressions by self, 25.5% endorsed transgressions by others, and 25.5% endorsed betrayal. PMIEs were moderately positively associated with combat severity (β = .23, P < .001) and negatively associated with white race, college education, and higher income (βs = .11-.16, Ps < .05). Transgressions by self were associated with current mental disorders (OR = 1.65, P < .001) and suicidal ideation (OR = 1.67, P < .001); betrayal was associated with postdeployment suicide attempts (OR = 1.99, P < .05), even after conservative adjustment for covariates, including combat severity. A significant minority of U.S combat veterans report PMIEs related to their military service. PMIEs are associated with risk for mental disorders and suicidality, even after adjustment for sociodemographic variables, trauma and combat exposure histories, and past psychiatric disorders.

Measuring Moral Injury: Psychometric Properties of the Moral Injury Events Scale in Two Military Samples.

As the construct of moral injury has gained increased conceptual and empirical attention among military personnel and veterans, preliminary attempts to operationalize and measure the construct have emerged. One such measure is the Moral Injury Event Scale (MIES). The aim of the current study was to further evaluate the MIES's psychometric properties in two military samples: a clinical sample of Air Force personnel and a nonclinical sample of Army National Guard personnel. Exploratory and confirmatory factor analyses across both samples supported a three-factor solution: transgressions by others, transgressions by self, and betrayal. Transgressions-Others was most strongly associated with posttraumatic stress; Transgressions-Self was most strongly associated with hopelessness, pessimism, and anger; and Betrayal was most strongly associated with posttraumatic stress and anger. Results support the construct validity of the MIES, although areas for improvement are indicated and discussed.

The Psychiatric Ramifications of Moral Injury Among Veterans

The Psychiatric Ramifications of Moral Injury Among Veterans

Psychometric Evaluation of the Moral Injury Events Scale

Literature describing the phenomenology of the stress of combat suggests that war-zone experiences may lead to adverse psychological outcomes such as post-traumatic stress disorder not only because they expose persons to life threat and loss but also because they may contradict deeply held moral and ethical beliefs and expectations. We sought to develop and validate a measure of potentially morally injurious events as a necessary step toward studying moral injury as a possible adverse consequence of combat. We administered an 11-item, self-report Moral Injury Events Scale to active duty Marines 1 week and 3 months following war-zone deployment. Two items were eliminated because of low item-total correlations. The remaining 9 items were subjected to an exploratory factor analysis, which revealed two latent factors that we labeled perceived transgressions and perceived betrayals; these were confirmed via confirmatory factor analysis on an independent sample. The overall Moral Injury Events Scale and its two subscales had favorable internal validity, and comparisons between the 1-week and 3-month data suggested good temporal stability. Initial discriminant and concurrent validity were also established. Future research directions were discussed.