Studies of moral injury

I was unfamiliar with the term ‘moral injury’ and found two interesting studies that help explain it. First, Hall & Neighbors (2024) published “Positive Associations Between Potentially Morally Injurious Experiences and Alcohol Outcomes in College Students: Results from a dominance analysis” in Psychological Trauma: Theory, Research, Practice, and Policy. Here are the abstract and impact statements:

A novel framework for understanding college students’ alcohol use is moral injury—psychological distress that stems from events that violate moral beliefs. Considering the predominantly positive associations between moral injury and alcohol use in military samples, this relationship may extend to students. The purpose of this study was to examine the association between potentially morally injurious experiences (PMIEs), alcohol use, and related consequences. Furthermore, we aimed to determine the relative importance of PMIE subtypes on alcohol outcomes. Participants included 604 college students (78% female; 38% Caucasian) with a mean age of 21 years (SD = 4.44). We hypothesized that (a) the composite PMIE score would be positively associated with alcohol consumption and consequences and (b) Commission with Agency would have the strongest association with alcohol outcomes, followed by Betrayal, Omission, Commission under Duress, posttraumatic stress (PTS) symptoms, and Witnessing. Analyses revealed that PMIEs [potentially morally injurious behaviors] were positively associated with alcohol-related consequences but not drinks per week when controlling for PTS [posttraumatic stress] symptoms. Moreover, the dominance analysis showed that Commission with Agency had the strongest association with consumption, followed by Betrayal, PTS symptoms, Commission under Duress, Witnessing, and Omission. PTS symptoms had the strongest association with alcohol-related consequences, followed by Commission with Agency, Commission under Duress, Omission, Betrayal, and Witnessing. These findings help distinguish moral injury constructs from PTS and highlight the importance of Commission with Agency in analyzing alcohol outcomes. 

This study provides evidence that both potentially morally injurious experiences (PMIEs) and posttraumatic stress symptoms are uniquely associated with alcohol-related consequences. Mental health services at colleges and universities should expand to address moral injury, especially related to Commission with Agency, in treatment. Additionally, students receiving alcohol sanctions should be screened for PMIEs in order to enhance their rehabilitation. 

I like the distinction between morally injurious behavior and posttraumatic stress. Next,

Andrews et al. (2023) published “Development and Preliminary Evaluation of the Moral Injury Assessment for Survivors of Abuse” in Traumatology.  Here’s the edited abstract:

Survivors of abuse (SoA) are exposed to violations of their trust and moral standards leading to the risk of experiencing significant psychological, spiritual, and behavioral suffering. However, little research has examined these experiences of moral injury (MI) in this population. Further, to our knowledge, there are no existing tools to measure MI in SoA. The Moral Injury Assessment for Survivors of Abuse was developed over multiple stages including literature review, focus groups with SoA, and consultations with clinical and research experts in relevant disciplines. The tool was piloted with 188 Canadian and American adult participants (M = 33.5 years old, standard deviation, SD = 9.2; 55% male-identified) and an exploratory factor analysis was conducted. Four distinct factors emerged that explained 60% of total variance: intergenerational transmission of trauma, emotional sequelae, self-blame, and betrayals. Further, the scale demonstrated strong internal reliability (total score: Cronbach’s α = .93), item-total correlations, and construct validity when compared to relevant measures of psychological distress. These findings present important preliminary insight into the unique experiences of MI within the SoA population and provide a foundation for future validation studies. Ultimately, it can potentially provide an additional tool for clinicians in developing tailored assessments and treatment plans for SoA. 

I was able to find references to several other assessments of moral injury and studies examining it in relation to clergy abuse, intimate partner violence and other experiences that may evoke moral injury. I will continue to look for more studies.