Moral Injury: An Increasingly Recognized and Widespread Syndrome

Abstract

Moral injury (MI), originally discussed in relationship to transgressing moral beliefs and values during wartime among military personnel, has expanded beyond this context to include similar emotions experienced by healthcare professionals, first responders, and others experiencing moral emotions resulting from actions taken or observations made during traumatic events or circumstances. In this article, we review the history, definition, measurement, prevalence, distinctiveness, psychological consequences, manifestations (in and outside of military settings), and correlates of MI in different settings. We also review secular psychological treatments, spiritually integrated therapies, and pastoral care approaches (specific for clergy and chaplains) used to treat MI and the evidence documenting their efficacy. Finally, we examine directions for future research needed to fill the many gaps in our knowledge about MI, how it develops, and how to help those suffering from it.

Morally Injurious Experiences and Emotions of Health Care Professionals During the COVID-19 Pandemic Before Vaccine Availability

“… 14 This qualitative study adds additional context to these numbers; the emotions reported—isolation, alienation, betrayal—significantly overlapped with the symptoms of moral injury in military and veteran populations. 28 Some respondents who had expressed these emotions were so distressed to the point where their entire lives had changed dramatically, whereas others who have experienced the same events were disturbed but not as affected in their functioning.…”

Moral Injury, Chaplaincy and Mental Health Provider Approaches to Treatment: A Scoping Review

“…These events are described as potentially morally injurious events (PMIEs), recognizing that not everyone exposed will be impacted in the same way. Evidence from a range of studies in United States (US) military samples suggests that individuals exposed to PMIEs are at greater risk of developing mental health issues, including more severe post-traumatic stress disorder (PTSD), depression, anxiety, and suicidality (summarized in Koenig & Al Zaben, 2021 ).…”

“…There has been a surge of interest in MI research in recent years focusing on efforts to understand and frame the construct of MI and the prevalence of MI in diverse populations (e.g., military personnel, veterans, police and other first responders), recently including healthcare workers in the context of the COVID-19 pandemic (Koenig & Al Zaben, 2021 ). The research has been led by mental health-related disciplines (e.g., psychology, psychiatry) as well as spiritual and religious disciplines (e.g., chaplaincy), all of which have played important roles in conceptualizing and developing approaches to address MI.…”

“…There is evidence that spiritually integrated psychotherapies, as well as chaplain facilitated pastoral care approaches, may be effective adjuncts or alternatives for addressing MI (e.g., Carey & Hodgson, 2018 ; Cenkner et al, 2021 ). The potential benefits of these approaches may be associated with addressing the spiritual impacts of moral transgressions (Carey et al, 2016 ; Koenig & Al Zaben, 2021 ).…”

“…While this review included three interventions that target MI (Adaptive Disclosure, Impact of Killing and Building Spiritual Strength) other intervention approaches used by mental health professionals and chaplains to address MI were not included. A second narrative review (Koenig & Al Zaben, 2021 ) identified several additional psychological approaches, spiritual/religious integrated approaches and pastoral care approaches. This review provided a brief description of the available approaches to MI but did not present evidence of intervention effectiveness.…”