Moral Injury
Table of Contents
1. Assessment Tools
2. Empirical Studies
3. Epidemiology
4. Interdisciplinary Perspectives
5. Review Articles
6. Theory
7. Treatment
8. COVID Pandemic
Assessment Tools
Assessing Exposure to Potentially Morally Injurious Events
Bryan, C. J., Bryan, A. O., Anestis, M. D., Anestis, J. C., Green, B. A., Etienne, N., Morrow, C. E., & Ray-Sannerud, B. (2016). Measuring Moral Injury: Psychometric Properties of the Moral Injury Events Scale in Two Military Samples. Assessment, 23(5), 557–570. https://doi.org/10.1177/1073191115590855
Nash, W.P., Marino, T.L., Carper, M., Mills, M.A., Au, T., Goldsmith, A., Litz, B.T. (2013). Psychometric Evaluation of the Moral Injury Events Scale. Military medicine, 178(6), 646-652. https://doi.org/10.7205/MILMED-D-13-00017
Moral Injury-Related Outcomes
Braitman, A. L., Battles, A. R., Kelley, M. L., Hamrick, H. C., Cramer, R. J., Ehlke, S., & Bravo, A. J. (2018). Psychometric properties of a Modified Moral Injury Questionnaire in a military population. Traumatology, 24(4), 301–312. https://doi.org/10.1037/trm0000158
Currier, J. M., Holland, J. M., Drescher, K., & Foy, D. (2015). Initial Psychometric Evaluation of the Moral Injury Questionnaire-Military Version. Clinical Psychology & Psychotherapy, 22(1), 54–63. https://doi.org/10.1002/cpp.1866
Currier, J. M., Farnsworth, J. K., Drescher, K. D., McDermott, R. C., Sims, B. M., & Albright, D. L. (2017). Development and evaluation of the Expressions of Moral Injury Scale-Military Version. Clinical Psychology & Psychotherapy, 25(3), 474–488. https://doi.org/10.1002/cpp.2170
Currier, J. M., Isaak, S. L., & McDermott, R. C. (2019). Validation of the Expressions of Moral Injury Scale‐Military version‐Short Form. Clinical Psychology & Psychotherapy, 27(1), 61–68. https://doi.org/10.1002/cpp.2407
Yeterian, J. D., Berke, D. S., Carney, J. R., McIntyre‐Smith, A., St. Cyr, K., King, L., Kline, N. K., Phelps, A., & Litz, B. T. (2019). Defining and Measuring Moral Injury: Rationale, Design, and Preliminary Findings From the Moral Injury Outcome Scale Consortium. Journal of Traumatic Stress, 32(3), 363–372. https://doi.org/10.1002/jts.22380
Empirical Studies
Moral Injury, Suicide and Mental Health
Battles, A. R., Kelley, M. L., Jinkerson, J. D., C. Hamrick, H., & F. Hollis, B. (2019). Associations Among Exposure to Potentially Morally Injurious Experiences, Spiritual Injury, and Alcohol Use Among Combat Veterans. Journal of Traumatic Stress, 32(3), 405–413. https://doi.org/10.1002/jts.22404
Bryan, A. O., Bryan, C. J., Morrow, C. E., Etienne, N., & Ray-Sannerud, B. (2014). Moral injury, suicidal ideation, and suicide attempts in a military sample. Traumatology, 20(3), 154–160. https://doi.org/10.1037/h0099852
Currier, J. M., Holland, J. M., & Malott, J. (2014). Moral Injury, Meaning Making, and Mental Health in Returning Veterans. Journal of Clinical Psychology, 71(3), 229–240. https://doi.org/10.1002/jclp.22134
Davies, R. L., Prince, M. A., Bravo, A. J., Kelley, M. L., & Crain, T. L. (2019). Moral Injury, Substance Use, and Posttraumatic Stress Disorder Symptoms Among Military Personnel: An Examination of Trait Mindfulness as a Moderator. Journal of Traumatic Stress, 32(3), 414–423. https://doi.org/10.1002/jts.22403
Fani, N., Currier, J. M., Turner, M. D., Guelfo, A., Kloess, M., Jain, J., Mekawi, Y., Kuzyk, E., Hinrichs, R., Bradley, B., Powers, A., Stevens, J. S., Michopoulos, V., & Turner, J. A. (2021). Moral injury in civilians: associations with trauma exposure, PTSD, and suicide behavior. European Journal of Psychotraumatology, 12(1). https://doi.org/10.1080/20008198.2021.1965464
Frankfurt, S. B., DeBeer, B. B., Morissette, S. B., Kimbrel, N. A., La Bash, H., & Meyer, E. C. (2018). Mechanisms of Moral Injury Following Military Sexual Trauma and Combat in Post-9/11 U.S. War Veterans. Frontiers in Psychiatry, 9. https://doi.org/10.3389/fpsyt.2018.00520
Houtsma, C., Khazem, L. R., Green, B. A., & Anestis, M. D. (2017). Isolating effects of moral injury and low post-deployment support within the U.S. military. Psychiatry Research, 247, 194–199. https://doi.org/10.1016/j.psychres.2016.11.031
Levi-Belz, Y., & Zerach, G. (2018). Moral injury, suicide ideation, and behavior among combat veterans: The mediating roles of entrapment and depression. Psychiatry Research, 269, 508–516. https://doi.org/10.1016/j.psychres.2018.08.105
Maguen, S., Nichter, B., Norman, S. B., & Pietrzak, R. H. (2021). Moral injury and substance use disorders among US combat veterans: results from the 2019–2020 National Health and Resilience in Veterans Study. Psychological Medicine, 1–7. https://doi.org/10.1017/s0033291721002919
Nichter, B., Norman, S. B., Maguen, S., & Pietrzak, R. H. (2021). Moral injury and suicidal behavior among US combat veterans: Results from the 2019–2020 National Health and Resilience in Veterans Study. Depression and Anxiety, 38(6), 606–614. https://doi.org/10.1002/da.23145
Schwartz, G., Halperin, E., & Levi-Belz, Y. (2021). Moral Injury and Suicide Ideation Among Combat Veterans: The Role of Trauma-Related Shame and Collective Hatred. Journal of Interpersonal Violence, 088626052110079. https://doi.org/10.1177/08862605211007932
Schwartz, G., Halperin, E., & Levi-Belz, Y. (2021). Moral Injury and Suicide Ideation Among Combat Veterans: The Role of Trauma-Related Shame and Collective Hatred. Journal of Interpersonal Violence, 088626052110079. https://doi.org/10.1177/08862605211007932
Zerach, G., & Levi-Belz, Y. (2018). Moral injury process and its psychological consequences among Israeli combat veterans. Journal of Clinical Psychology, 74(9), 1526–1544. https://doi.org/10.1002/jclp.22598
Zerach, G., & Levi‐Belz, Y. (2019). Intolerance of Uncertainty Moderates the Association Between Potentially Morally Injurious Events and Suicide Ideation and Behavior Among Combat Veterans. Journal of Traumatic Stress, 32(3), 424–436. https://doi.org/10.1002/jts.22366
Potentially Morally Injurious Events
Drescher, K. D., Foy, D. W., Kelly, C., Leshner, A., Schutz, K., & Litz, B. (2011). An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology, 17(1), 8–13. https://doi.org/10.1177/1534765610395615
Houle, S. A., Vincent, C., Jetly, R., & Ashbaugh, A. R. (2021). Patterns of distress associated with exposure to potentially morally injurious events among Canadian Armed Forces service members and Veterans: A multi‐method analysis. Journal of Clinical Psychology, 77(11), 2668–2693. https://doi.org/10.1002/jclp.23205
Maguen, S., Griffin, B. J., Copeland, L. A., Perkins, D. F., Finley, E. P., & Vogt, D. (2020). Gender differences in prevalence and outcomes of exposure to potentially morally injurious events among post-9/11 veterans. Journal of Psychiatric Research, 130, 97–103. https://doi.org/10.1016/j.jpsychires.2020.06.020
Schorr, Y., Stein, N. R., Maguen, S., Barnes, J. B., Bosch, J., & Litz, B. T. (2018). Sources of moral injury among war veterans: A qualitative evaluation. Journal of Clinical Psychology, 74(12), 2203–2218. https://doi.org/10.1002/jclp.22660
Vargas, A. F., Hanson, T., Kraus, D., Drescher, K., & Foy, D. (2013). Moral injury themes in combat veterans’ narrative responses from the National Vietnam Veterans’ Readjustment Study. Traumatology, 19(3), 243–250. https://doi.org/10.1177/1534765613476099
Understanding Moral Injury as Distinct from PTSD
Barnes, H. A., Hurley, R. A., & Taber, K. H. (2019). Moral Injury and PTSD: Often Co-Occurring Yet Mechanistically Different. The Journal of Neuropsychiatry and Clinical Neurosciences, 31(2), A4-103. https://doi.org/10.1176/appi.neuropsych.19020036
Boska, R. L., & Capron, D. W. (2021). Exploring the maladaptive cognitions of moral injury within a primarily combat-trauma military sample. Psychological Trauma: Theory, Research, Practice, and Policy, 13(8), 861–868. https://doi.org/10.1037/tra0001071
Bryan, C. J., Bryan, A. O., Roberge, E., Leifker, F. R., & Rozek, D. C. (2018). Moral injury, posttraumatic stress disorder, and suicidal behavior among National Guard personnel. Psychological Trauma: Theory, Research, Practice, and Policy, 10(1), 36–45. https://doi.org/10.1037/tra0000290
Currier, J. M., McDermott, R. C., Farnsworth, J. K., & Borges, L. M. (2019). Temporal Associations Between Moral Injury and Posttraumatic Stress Disorder Symptom Clusters in Military Veterans. Journal of Traumatic Stress, 32(3), 382–392. https://doi.org/10.1002/jts.22367
Jordan, A. H., Eisen, E., Bolton, E., Nash, W. P., & Litz, B. T. (2017b). Distinguishing war-related PTSD resulting from perpetration- and betrayal-based morally injurious events. Psychological Trauma: Theory, Research, Practice, and Policy, 9(6), 627–634. https://doi.org/10.1037/tra0000249
Koenig, H. G., Youssef, N. A., Ames, D., Teng, E. J., & Hill, T. D. (2019). Examining the Overlap Between Moral Injury and PTSD in US Veterans and Active Duty Military. Journal of Nervous & Mental Disease, 208(1), 7–12. https://doi.org/10.1097/nmd.0000000000001077
Levi-Belz, Y., Greene, T., & Zerach, G. (2020). Associations between moral injury, PTSD clusters, and depression among Israeli veterans: a network approach. European Journal of Psychotraumatology, 11(1), 1736411. https://doi.org/10.1080/20008198.2020.1736411
Epidemiology
Trauma Types
Litz, B. T., Contractor, A. A., Rhodes, C., Dondanville, K. A., Jordan, A. H., Resick, P. A., Foa, E. B., Young‐McCaughan, S., Mintz, J., Yarvis, J. S., & Peterson, A. L. (2018). Distinct trauma types in military service members seeking treatment for posttraumatic stress disorder. Journal of Traumatic Stress, 31(2), 286–295. https://doi.org/10.1002/jts.22276
Stein, N. R., Mills, M. A., Arditte, K., Mendoza, C., Borah, A. M., Resick, P. A., Litz, B. T., Belinfante, K., Borah, E. V., Cooney, J. A., Foa, E. B., Hembree, E. A., Kippie, A., Lester, K., Malach, S. L., McClure, J., Peterson, A. L., Vargas, V., & Wright, E. (2012). A Scheme for Categorizing Traumatic Military Events. Behavior Modification, 36(6), 787–807. https://doi.org/10.1177/0145445512446945
Stein, J. Y., Wilmot, D. V., & Solomon, Z. (2016). Does one size fit all? Nosological, clinical, and scientific implications of variations in PTSD Criterion A. Journal of Anxiety Disorders, 43, 106–117. https://doi.org/10.1016/j.janxdis.2016.07.001
Prevalence
Wisco, B. E., Marx, B. P., May, C. L., Martini, B., Krystal, J. H., Southwick, S. M., & Pietrzak, R. H. (2017). Moral injury in U.S. combat veterans: Results from the national health and resilience in veterans study. Depression and Anxiety, 34(4), 340–347. https://doi.org/10.1002/da.22614
Interdisciplinary Perspectives
Social Work
Haight, W., Sugrue, E., Calhoun, M., & Black, J. (2016). A scoping study of moral injury: Identifying directions for social work research. Children and Youth Services Review, 70, 190–200. https://doi.org/10.1016/j.childyouth.2016.09.026
Blinka , D., & Harris, H.W. (2016). Moral injury in warriors and veterans: The challenge to social work. Social Work & Christianity,43(3), 7-27. https://psycnet.apa.org/record/2016-39484-002
Religious
Currier, J. M., Foster, J. D., & Isaak, S. L. (2019). Moral Injury and Spiritual Struggles in Military Veterans: A Latent Profile Analysis. Journal of Traumatic Stress, 32(3), 393–404. https://doi.org/10.1002/jts.22378
Drescher, K.D. & Foy, D.W. (2008). When they Come Home: Posttraumatic Stress, Moral Injury, and Spiritual Consequences for Veterans. Reflective Practice: Formation and Supervision in Ministry, 28. https://journals.sfu.ca/rpfs/index.php/rpfs/article/view/158/157
Hodgson, T. J., & Carey, L. B. (2017). Moral Injury and Definitional Clarity: Betrayal, Spirituality and the Role of Chaplains. Journal of Religion and Health, 56(4), 1212–1228. https://doi.org/10.1007/s10943-017-0407-z
Richardson, N. M., & Lamson, A. L. (2021). Understanding moral injury: Military-related injuries of the mind, body, and soul. Spirituality in Clinical Practice. https://doi.org/10.1037/scp0000270
Worthington, E. L., & Langberg, D. (2012). Religious Considerations and Self-Forgiveness in Treating Complex Trauma and Moral Injury in Present and Former Soldiers. Journal of Psychology and Theology, 40(4), 274–288. https://doi.org/10.1177/009164711204000403
Wortmann, J. H., Eisen, E., Hundert, C., Jordan, A. H., Smith, M. W., Nash, W. P., & Litz, B. T. (2017). Spiritual features of war-related moral injury: A primer for clinicians. Spirituality in Clinical Practice, 4(4), 249–261. https://doi.org/10.1037/scp0000140
Criminal Justice System
Brown, W., Stanulis, R., Weitzel, M., & Rodgers, K. (2015). “You probably don’t know who or what you are talking about”: Cultural and Moral Incompetence in Evaluating the Veteran in the Criminal Justice System. Justice Policy Journal, http://www.cjcj.org/uploads/cjcj/documents/jpj_brown_et_al_spring_2015.pdf
Rosenthal, J., & Finlay, A.K. (2022). Expanding the Scope of Forensic and Other Services for Justice-Involved Veterans. J Am Acad Psychiatry Law, 50(1). http://jaapl.org/content/jaapl/early/2022/01/14/JAAPL.210047-21.full.pdf
Occupations
Lentz, L. M., Smith-MacDonald, L., Malloy, D., Carleton, R. N., & Brémault-Phillips, S. (2021). Compromised Conscience: A Scoping Review of Moral Injury Among Firefighters, Paramedics, and Police Officers. Frontiers in Psychology, 12. https://doi.org/10.3389/fpsyg.2021.639781
Papazoglou, K., & Chopko, B. (2017). The Role of Moral Suffering (Moral Distress and Moral Injury) in Police Compassion Fatigue and PTSD: An Unexplored Topic. Frontiers in Psychology, 8. https://doi.org/10.3389/fpsyg.2017.01999
Stovall, M., Hansen, L., & Ryn, M. (2020). A Critical Review: Moral Injury in Nurses in the Aftermath of a Patient Safety Incident. Journal of Nursing Scholarship, 52(3), 320–328. https://doi.org/10.1111/jnu.12551
Reviews
Frankfurt, S., & Frazier, P. (2016). A Review of Research on Moral Injury in Combat Veterans. Military Psychology, 28(5), 318–330. https://doi.org/10.1037/mil0000132
Griffin, B. J., Purcell, N., Burkman, K., Litz, B. T., Bryan, C. J., Schmitz, M., Villierme, C., Walsh, J., & Maguen, S. (2019). Moral Injury: An Integrative Review. Journal of Traumatic Stress, 32(3), 350–362. https://doi.org/10.1002/jts.22362
Jinkerson, J. D. (2016). Defining and assessing moral injury: A syndrome perspective. Traumatology, 22(2), 122–130. https://doi.org/10.1037/trm0000069
Richardson, N. M., Lamson, A. L., Smith, M., Eagan, S. M., Zvonkovic, A. M., & Jensen, J. (2020). Defining Moral Injury Among Military Populations: A Systematic Review. Journal of Traumatic Stress, 33(4), 575–586. https://doi.org/10.1002/jts.22553
Steinmetz, S., & Gray, M. (2015). Treatment for Distress Associated with Accurate Appraisals of Self-Blame for Moral Transgressions. Current Psychiatry Reviews, 11(3), 207–219. https://doi.org/10.2174/1573400511666150629105709
Vermetten, E., & Jetly, R. (2018). A Critical Outlook on Combat-Related PTSD: Review and Case Reports of Guilt and Shame as Drivers for Moral Injury. Military Behavioral Health, 6(2), 156–164. https://doi.org/10.1080/21635781.2018.1459973
Williamson, V., Stevelink, S.A., Greenberg, N. (2018). Occupational moral injury and mental health: Systematic review and meta-analysis. The British Journal of Psychiatry, 212(6), 339-346. https://doi.org/10.1192/bjp.2018.55
Theory
Conceptualization
Antonelli, M. (2017). Moral Injury. The American Journal of Psychoanalysis, 77(4), 406–416. https://doi.org/10.1057/s11231-017-9107-4
Farnsworth, J. K. (2019). Is and Ought: Descriptive and Prescriptive Cognitions in Military‐Related Moral Injury. Journal of Traumatic Stress, 32(3), 373–381. https://doi.org/10.1002/jts.22356
Farnsworth, J. K., Drescher, K. D., Evans, W., & Walser, R. D. (2017). A functional approach to understanding and treating military-related moral injury. Journal of Contextual Behavioral Science, 6(4), 391–397. https://doi.org/10.1016/j.jcbs.2017.07.003
Farnsworth, J. K., Drescher, K. D., Nieuwsma, J. A., Walser, R. B., & Currier, J. M. (2014). The Role of Moral Emotions in Military Trauma: Implications for the Study and Treatment of Moral Injury. Review of General Psychology, 18(4), 249–262. https://doi.org/10.1037/gpr0000018
Jordan, A. H., Eisen, E., Bolton, E., Nash, W. P., & Litz, B. T. (2017). Distinguishing war-related PTSD resulting from perpetration- and betrayal-based morally injurious events. Psychological Trauma: Theory, Research, Practice, and Policy, 9(6), 627–634. https://doi.org/10.1037/tra0000249
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695–706. https://doi.org/10.1016/j.cpr.2009.07.003
Nickerson, A., Bryant, R. A., Rosebrock, L., & Litz, B. T. (2014). The mechanisms of psychosocial injury following human rights violations, mass trauma, and torture. Clinical Psychology: Science and Practice, 21(2), 172–191. https://doi.org/10.1111/cpsp.12064
Shay, J. (2012). Moral Injury. Intertexts, 16(1), 57–66. https://doi.org/10.1353/itx.2012.0000
Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2), 182–191. https://doi.org/10.1037/a0036090
Commentaries
Gray, M. J., Nash, W. P., & Litz, B. T. (2017). When Self-Blame Is Rational and Appropriate: The Limited Utility of Socratic Questioning in the Context of Moral Injury: Commentary on Wachen et al. (2016). Cognitive and Behavioral Practice, 24(4), 383–387. https://doi.org/10.1016/j.cbpra.2017.03.001
Nash, W. P. (2019). Commentary on the Special Issue on Moral Injury: Unpacking Two Models for Understanding Moral Injury. Journal of Traumatic Stress, 32(3), 465–470. https://doi.org/10.1002/jts.22409
Neria, Y., & Pickover, A. (2019). Commentary on the Special Issue on Moral Injury: Advances, Gaps in Literature, and Future Directions. Journal of Traumatic Stress, 32(3), 459–464. https://doi.org/10.1002/jts.22402
Wachen, J. S., Dondanville, K. A., & Resick, P. A. (2017). Correcting Misperceptions About Cognitive Processing Therapy to Treat Moral Injury: A Response to Gray and Colleagues (this issue). Cognitive and Behavioral Practice, 24(4), 388–392. https://doi.org/10.1016/j.cbpra.2017.06.001
Wachen, J. S., Dondanville, K. A., Pruiksma, K. E., Molino, A., Carson, C. S., Blankenship, A. E., Wilkinson, C., Yarvis, C. J. S., & Resick, P. A. (2016). Implementing Cognitive Processing Therapy for Posttraumatic Stress Disorder With Active Duty U.S. Military Personnel: Special Considerations and Case Examples. Cognitive and Behavioral Practice, 23(2), 133–147. https://doi.org/10.1016/j.cbpra.2015.08.007
Zalta, A. K., & Held, P. (2020). Commentary on the Special Issue on Moral Injury: Leveraging Existing Constructs to Test the Heuristic Model of Moral Injury. Journal of Traumatic Stress, 33(4), 598–599. https://doi.org/10.1002/jts.22516
Treatment
Acceptance and Commitment Therapy
Borges, L. M. (2019). A service member's experience of Acceptance and Commitment Therapy for Moral Injury (ACT-MI) via telehealth: “Learning to accept my pain and injury by reconnecting with my values and starting to live a meaningful life”. Journal of Contextual Behavioral Science, 13, 134-140. https://doi.org/10.1016/j.jcbs.2019.08.002
Farnsworth, J. K., Drescher, K. D., Evans, W., & Walser, R. D. (2017). A functional approach to understanding and treating military-related moral injury. Journal of Contextual Behavioral Science, 6(4), 391–397. https://doi.org/10.1016/j.jcbs.2017.07.003
Nieuwsma, J., Walser, R., Farnsworth, J., Drescher, K., Meador, K., & Nash, W. (2015). Possibilities within Acceptance and Commitment Therapy for Approaching Moral Injury. Current Psychiatry Reviews, 11(3), 193–206. https://doi.org/10.2174/1573400511666150629105234
Adaptive Disclosure
Gray, M. J., Schorr, Y., Nash, W., Lebowitz, L., Amidon, A., Lansing, A., Maglione, M., Lang, A. J., & Litz, B. T. (2012). Adaptive Disclosure: An Open Trial of a Novel Exposure-Based Intervention for Service Members With Combat-Related Psychological Stress Injuries. Behavior Therapy, 43(2), 407–415. https://doi.org/10.1016/j.beth.2011.09.001
Litz, B. T., Rusowicz-Orazem, L., Doros, G., Grunthal, B., Gray, M., Nash, W., & Lang, A. J. (2021). Adaptive disclosure, a combat-specific PTSD treatment, versus cognitive-processing therapy, in deployed marines and sailors: A randomized controlled non-inferiority trial. Psychiatry Research, 297, 113761. https://doi.org/10.1016/j.psychres.2021.113761
Litz, B., & Carney, J. R. (2018). Employing loving-kindness meditation to promote self- and other-compassion among war veterans with posttraumatic stress disorder. Spirituality in Clinical Practice, 5(3), 201–211. https://doi.org/10.1037/scp0000174
Impact of Killing CBT
Burkman, K., Purcell, N., & Maguen, S. (2018). Provider perspectives on a novel moral injury treatment for veterans: Initial assessment of acceptability and feasibility of the Impact of Killing treatment materials. Journal of Clinical Psychology, 75(1), 79–94. https://doi.org/10.1002/jclp.22702
Maguen, S., Burkman, K., Madden, E., Dinh, J., Bosch, J., Keyser, J., Schmitz, M., & Neylan, T. C. (2017). Impact of Killing in War: A Randomized, Controlled Pilot Trial. Journal of Clinical Psychology, 73(9), 997–1012. https://doi.org/10.1002/jclp.22471
Purcell, N., Burkman, K., Keyser, J., Fucella, P., & Maguen, S. (2018). Healing from Moral Injury: A Qualitative Evaluation of theImpact of KillingTreatment for Combat Veterans. Journal of Aggression, Maltreatment & Trauma, 27(6), 645–673. https://doi.org/10.1080/10926771.2018.1463582
Trauma Informed Guilt Reduction Therapy
Capone, C., Norman, S. B., Haller, M., Davis, B., Shea, M. T., Browne, K., Lang, A. J., Schnurr, P. P., Golshan, S., Afari, N., Pittman, J., Allard, C. B., & Westendorf, L. (2021). Trauma Informed Guilt Reduction (TrIGR) therapy for guilt, shame, and moral injury resulting from trauma: Rationale, design, and methodology of a two-site randomized controlled trial. Contemporary Clinical Trials, 101, 106251. https://doi.org/10.1016/j.cct.2020.106251
Norman, S. (2022). Trauma-Informed Guilt Reduction Therapy: Overview of the Treatment and Research. Current Treatment Options in Psychiatry. https://doi.org/10.1007/s40501-022-00261-7
Norman, S. B., Capone, C., Panza, K. E., Haller, M., Davis, B. C., Schnurr, P. P., Shea, M. T., Browne, K., Norman, G. J., Lang, A. J., Kline, A. C., Golshan, S., Allard, C. B., & Angkaw, A. (2022). A clinical trial comparing trauma‐informed guilt reduction therapy (TrIGR), a brief intervention for trauma‐related guilt, to supportive care therapy. Depression and Anxiety, 39(4), 262–273. https://doi.org/10.1002/da.23244
Norman, S. B., Wilkins, K. C., Myers, U. S., & Allard, C. B. (2014). Trauma Informed Guilt Reduction Therapy With Combat Veterans. Cognitive and Behavioral Practice, 21(1), 78–88. https://doi.org/10.1016/j.cbpra.2013.08.001
Cognitive and Exposure-based Treatments
Held, P., Klassen, B. J., Brennan, M. B., & Zalta, A. K. (2018). Using Prolonged Exposure and Cognitive Processing Therapy to Treat Veterans With Moral Injury-Based PTSD: Two Case Examples. Cognitive and Behavioral Practice, 25(3), 377–390. https://doi.org/10.1016/j.cbpra.2017.09.003
Held, P., Klassen, B. J., Hall, J. M., Friese, T. R., Bertsch-Gout, M. M., Zalta, A. K., & Pollack, M. H. (2019). “I knew it was wrong the moment I got the order”: A narrative thematic analysis of moral injury in combat veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 11(4), 396–405. https://doi.org/10.1037/tra0000364
Held, P., Klassen, B. J., Steigerwald, V. L., Smith, D. L., Bravo, K., Rozek, D. C., van Horn, R., & Zalta, A. (2021). Do morally injurious experiences and index events negatively impact intensive PTSD treatment outcomes among combat veterans? European Journal of Psychotraumatology, 12(1). https://doi.org/10.1080/20008198.2021.1877026
Murray, H., & Ehlers, A. (2021). Cognitive therapy for moral injury in post-traumatic stress disorder. The Cognitive Behaviour Therapist, 14. https://doi.org/10.1017/s1754470x21000040
Smith, E. R., Duax, J. M., & Rauch, S. A. (2013). Perceived Perpetration During Traumatic Events: Clinical Suggestions From Experts in Prolonged Exposure Therapy. Cognitive and Behavioral Practice, 20(4), 461–470. https://doi.org/10.1016/j.cbpra.2012.12.002
Wachen, J. S., Dondanville, K. A., Pruiksma, K. E., Molino, A., Carson, C. S., Blankenship, A. E., Wilkinson, C., Yarvis, C. J. S., & Resick, P. A. (2016). Implementing Cognitive Processing Therapy for Posttraumatic Stress Disorder With Active Duty U.S. Military Personnel: Special Considerations and Case Examples. Cognitive and Behavioral Practice, 23(2), 133–147. https://doi.org/10.1016/j.cbpra.2015.08.007
Commentaries
Rauch, S. A., Smith, E., Duax, J., & Tuerk, P. (2013). A Data-Driven Perspective: Response to Commentaries by Maguen and Burkman (2013) and Steenkamp et al. (2013). Cognitive and Behavioral Practice, 20(4), 480–484. https://doi.org/10.1016/j.cbpra.2013.07.002
Steenkamp, M. M., Nash, W. P., Lebowitz, L., & Litz, B. T. (2013). How Best to Treat Deployment-Related Guilt and Shame: Commentary on Smith, Duax, and Rauch (2013). Cognitive and Behavioral Practice, 20(4), 471–475. https://doi.org/10.1016/j.cbpra.2013.05.002
Additional
Borges, L. M., Bahraini, N. H., Holliman, B. D., Gissen, M. R., Lawson, W. C., & Barnes, S. M. (2019). Veterans’ perspectives on discussing moral injury in the context of evidence‐based psychotherapies for PTSD and other VA treatment. Journal of Clinical Psychology, 76(3), 377–391. https://doi.org/10.1002/jclp.22887
Nazarov, A., Fikretoglu, D., Liu, A., Richardson, J. D., & Thompson, M. (2020). Help-seeking for mental health issues in deployed Canadian Armed Forces personnel at risk for moral injury. European Journal of Psychotraumatology, 11(1), 1729032. https://doi.org/10.1080/20008198.2020.1729032
Purcell, N., Griffin, B. J., Burkman, K., & Maguen, S. (2018). “Opening a Door to a New Life”: The Role of Forgiveness in Healing From Moral Injury. Frontiers in Psychiatry, 9. https://doi.org/10.3389/fpsyt.2018.00498
COVID Pandemic
Dean, W., Talbot, S., & Dean, A. (2019). Reframing Clinician Distress: Moral Injury Not Burnout. Fed Pract., 36(9), 400-402. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6752815/
Ducharlet, K., Trivedi, M., Gelfand, S. L., Liew, H., McMahon, L. P., Ashuntantang, G., Brennan, F., Brown, & Martin, D. E. (2021). Moral distress and moral injury in nephrology during the COVID-19 pandemic, Seminars in Nephrology, 41(3), 253-261. https://doi.org/10.1016/j.semnephrol.2021.05.006
Greenberg, N., Docherty, M., Gnanapragasam, S., & Wessely, S. (2020). Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ, m1211. https://doi.org/10.1136/bmj.m1211
Nieuwsma, J. A., O’Brien, E. C., Xu, H., Smigelsky, M. A., & Meador, K. G. (2022). Patterns of Potential Moral Injury in Post-9/11 Combat Veterans and COVID-19 Healthcare Workers. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-022-07487-4
Shale, S. (2020). Moral injury and the COVID-19 pandemic: Reframing what it is, who it affects and how care leaders can manage it. BMJ Leader, 4(4), 224–227. https://doi.org/10.1136/leader-2020-000295
Williams, R. D., Brundage, J. A., & Williams, E. B. (2020). Moral Injury in Times of COVID-19. Journal of Health Service Psychology, 46(2), 65–69. https://doi.org/10.1007/s42843-020-00011-4
Williamson, V., Murphy, D., & Greenberg, N. (2020). COVID-19 and experiences of moral injury in front-line key workers. Occupational Medicine, 70(5), 317–319. https://doi.org/10.1093/occmed/kqaa052
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