Contextual dimensions of moral injury: An interdisciplinary review

Abstract

The concept of moral injury, referring to the psychological impact of having one’s moral expectations and beliefs violated, is gaining a firm place in research on military trauma. Yet, although moral injury has the recognized potential to extend the understanding of trauma beyond the individualizing and pathologizing focus of the clinical realm, most studies nevertheless focus on clinical assessment, diagnosis and treatment. This review aims to contribute to a better understanding of contextual dimensions of moral injury. To this end, it complements current theory on moral injury with a systematic review of literature relevant to contextual factors in moral injury. It draws together insights from psychology, philosophy, theology and social sciences into spiritual/existential, organizational, political and societal dimensions of moral injury. Thus an interdisciplinary theoretical foundation is created for context-sensitive research and interventions.

Caught between is and ought: The Moral Dissonance Model

“…Building upon established theories and frameworks, we propose the Moral Dissonance Model (MDM) as a visualization of the continuous interplay between individual experience and contextual aspects. We believe that such a model is applicable to a wider context than the military, a research direction advocated by the reviews of Molendijk et al (5) and Griffin et al (1).…”

“…The concept of moral injury is rooted in discontent with dominant theory and treatment regarding post-traumatic stress disorder (PTSD). Although PTSD and moral injury show overlap in their respective symptomatology (2,4), the moral and social dimensions of military distress were believed to be lacking in the current definition of PTSD (3)(4)(5)(6)(7). Thus, around a decade ago, military psychiatrists and psychologists adapted the concept moral injury to capture moral conflict-colored feelings of shame, guilt, betrayal and anger as a result of soldiers' deployment (5).…”

“…Most current studies on moral injury focus on its clinical assessment [e.g., (1,(8)(9)(10)(11)]. As noted by Molendijk et al (5), a consequence of such a focus is that moral injury is turned ". .…”

“…Contextual factors are all circumstances surrounding the individual's experience of an event, and include (military) culture, political mandate, and societal attitudes. These circumstances contribute to the occurrence of moral distress [e.g., (1,5)]. For instance, Molendijk and colleagues (18,19) describe how moral distress results from political decision-making and framing, but also from a lack of societal recognition (e.g., criticism and/or misplaced admiration regarding military missions).…”

Editorial: Emerging treatments and approaches for moral injury and moral distress

“…The field of psychiatry, for example, may be considering situating MI/MD within current diagnostic classifications; there may be support for a subtype of MI as part of PTSD ( 8 ). Other perspectives advocate for a broader interdisciplinary public health perspective of MI/MD ( 9 , 10 ). There is a clear need to broaden the horizon to include domains such as morals and ethics, spirituality and religion, and philosophy and anthropology.…”