What’s Missing in Moral Injury Research

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Moral injury (MI) is a term that refers to the emotional trauma a military service member feels when his or her sense of moral rightness is violated during the course of war (Currier, Holland, Drescher, & Foy, 2015a; Currier, McCormick, & Drescher, 2015b; Nash, Carper, Mills, Au, Goldsmith, & Litz, 2013). MI addresses a gap in PTSD formulations. Various research efforts have been made to establish an MI construct and instruments for measuring moral injurious events. Both the MI framework and its associated scales were developed using a low percentage of women as participants.

Moral Injury Constructs

The extant literature uses multiple definitions for moral injury. The most narrow version, offered by Shay (2014), states that moral injury might occur when a leader in a high stakes situation violates a moral law. All three elements — moral violation, by a person in a position of authority, in a high stakes situation — must be present for moral injury to occur. Much like the Great Man leadership theories from centuries ago, in which the leader has a “duty of care” for his or her subordinates and the followers have a “duty of loyalty,” Shay casts military leaders as shepherds to their flocks. Shay does not provide definitions of what he considers to be a moral violation or a high stakes situation, but the examples he uses are generally combat related.

Others have expanded the description of the causes of moral injury. Litz et al. (2009) stated that “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” (p. 700) could cause MI. Nash et al. (2013) used the same description in their research related to moral injury. In Jinkerson’s (2016) assessment of potentially moral injurious events (MIEs), he states that a MIE may occur “when one violates his or her moral beliefs, is betrayed, or witnesses trusted individuals committing atrocities” (p. 122).

Drescher, Foy, Kelly, Leshner, Schutz, and Litz (2011) approached the development of a moral injury construct by gathering data from a select group of care providers. Qualitative interviews were conducted with 11 chaplains, 11 mental health workers, and one educator. Eight of the participants worked in the Department of Defense (DoD), and nine were from the Veterans Affairs (VA) department. Four of the participants were women. Participants were asked to help define moral injury, whether PTSD formulations adequately covered the long term effects of MIEs, the types of events that might contribute to MI, and what might be the long term effects of moral injury.

The results suggested that the moral injury construct needs improvement. All of the participants agreed that the MI term is needed because PTSD does not adequately capture the trauma experienced in a war zone. There was also unanimous agreement that the provided definition of moral injury — “disruption in an individual’s confidence and expectations about one’s own or others’ motivation or capacity to behave in a just and ethical manner” — was inadequate. Participants suggested that the list of events that could cause moral injury should include betrayal, disproportionate violence, harm to civilians, and in-ranks violence (such as sexual assault).

Moral Injury Instruments

Moral Injury Questionnaire — Military Version

The two most common instruments for measuring moral injurious events are the Moral Injury Questionnaire — Military version (MIQ-M; Currier et al., 2015a) and the Moral Injury Event Scale (MIES; Nash et al., 2013). The MIQ-M contains 20 items and is designed to measure MIEs for military personnel. Items are divided into six categories: acts of betrayal, disproportionate violence perpetrated on others, harm to civilians, in-rank violence, inability to prevent suffering, and ethical/moral dilemmas. The MIQ-M measures the frequency of each item on a four-point scale: 1-Never, 2-Seldom, 3-Sometimes, and 4-Often.

Currier et al. (2015a) conducted an initial psychometric evaluation of MIQ-M. The first sample included 131 veterans from the wars in Iraq and Afghanistan, 13% of whom were female. The second sample consisted of 82 male veterans who were in a rehabilitation program for those with PTSD. Second sample participants also completed the Combat Experiences Scale (CES), the Work and Social Adjustment Scale (WSAS) to measure impairment in social and occupational functioning, and the Suicidal Behaviors Questionnaire (SBQ-R) to determine suicide risk. The Posttraumatic Stress Disorder — Civilian (PCL-C) was used to assess PTSD symptoms, and depression was measured using the Patient Health Questionnaire (PHQ-9). Results showed that greater MIQ-M scores were associated with greater combat exposure, lower work and social adjustment, greater PTSD symptoms, and increased depression.

Moral Injury Events Scales

The Moral Injury Events Scale (MIES) was developed and evaluated by Nash et al. (2013). MIES is an eleven item instrument created by “a team of experts”, but the composition of the experts was not described in the research article. The MIES is designed to measure traumatic events that violate deeply held moral/religious views and that might lead to PTSD. The scale addresses two categories of events: violations of moral beliefs by self or others and issues of trust. To validate the scale, researchers used male-only Marine Corps infantry battalions who deployed to Iraq and Afghanistan. The authors acknowledged that further testing with female service members needed to be done.

Bryan et al. (2016) conducted a psychometric evaluation of MIES using participants from the Air Force and Army National Guard. The first sample consisted of 151 active Air Force personnel who were getting outpatient mental health treatment. Just over one third of the sample was female. The second sample was made up of 935 Army National guard members who were demobilizing after an Afghanistan deployment. Eighteen percent of this sample were female.

Results varied somewhat from those obtained by the original evaluation by Nash et al. (2013). Rather than the two-factor solution, Bryan et al. (2016) found three factors: moral violations committed by self, violations committed by others, and betrayal by others. Based on item intercorrelation scores, the authors suggested that the number of Transgression-Self items and Transgression-Others items should be increased to capture a broader range of events. No significant difference between mean scores for men and women were found in either sample. Authors suggested that diagnostic interviews could further evaluate the instrument’s construct validity.

Neither the MIQ-M or MIES were developed or tested using a significant number of women. While the military population is approximately 15% female (2011 Demographics profile of the military community, 2012), oversampling for women might be necessary to discover the entire range of women’s military experiences that may contribute to MI. Women encounter a variety of stressors in disproportion to men. According to the Congressional Research Service (2017), women account for approximately 2% of the wounded and killed in action from Operations Enduring Freedom and Iraqi Freedom. On the other hand, up to 84% of military women experienced sexual harassment, and one third experienced rape or attempted rape while serving in the military (Turchik & Wilson, 2010). In-service sexual assault rates for men were reported at 4% or lower and the reported rate of sexual harassment for military men was as high as 74% (Turchik & Wilson, 2010). Ruiz-Cantero et al. (2007) explained the importance of considering gender and class, as well as power inequalities between men and women in health research. Not adequately considering gender in research is likely to lead to biased results (Ruiz-Cantero, 2007). MIQ-M and MIES were validated using female sample sizes of 20% or less.

Conclusion

What’s missing is that current concepts of moral injury do not adequately account for the social and institutional context in which military women work while serving as members of the U.S. warfighting community. A review of contemporary MI descriptions and instruments showed that not enough women were included in the research. Another study showed that women experience the military differently than men (Roberts, Kovacich, & Rivers, 2017).

To correct this problem, we are conducting a study entitled, “Moral Injury for Women Veterans: A Grounded Theory Study” (see Current Projects page). We are seeking U.S. women veterans who served in the Army, Navy, Air Force, Marines, or Coast Guard, either on active duty, in the reserves, or National Guard. To qualify, you must be between the age of 25 and 70; a retired or discharged uniformed service member with at least five years of service; of the grade of E-5 or above as an enlisted person, W-2 or above as a warrant officer, or O-3 or above as an officer at the time you left the service; not currently working for the Department of Defense as a civilian or contractor; and a witness to, participant in, or the target of any activities by military personnel that created inner conflict or violated your personal moral values.

To take part in the study or request additional information, please contact: 
Dr. Daniel Roberts, 910-690-5964, droberts@chaplainconsultants.com

References

Berg, Susan H. (2002). ‘The PTSD Diagnosis: Is It Good for Women? Affilia, 17(1): 55-68.

Bryan, Craig J., Bryan, AnnaBelle O., Anestis, Michael D., … Ray-Sannerud, Bobbie (2016). ‘Measuring Moral Injury: Psychometric Properties of the Moral Injury Events Scale in Two Military Samples’. Assessment, 23(5): 557-570.

Congressional Research Service (2017). American War and Military Operations Casualties: Lists and Statistics (CRS Publication No. RL32492). Available at: https://fas.org/sgp/crs/natsec/RL32492.pdf (accessed 26 March 2018).

Currier, Joseph M., Holland, Jason M., Drescher, Kent, & Foy, David (2015a). ‘Initial Psychometric Evaluation of the Moral Injury Questionnaire—Military version’. Clinical Psychology and Psychotherapy, 22(1): 54-63.

Currier, Joseph M., McCormick, Wesley, & Drescher, Kent D. (2015b). ‘How Do Morally Injurious Events Occur? A Qualitative Analysis of Perspectives of Veterans with PTSD’. Traumatology, 21(2): 106-116.

Department of Defense (DoD) (2012). 2011 Demographics Profile of the Military Community. Available at: http://www.militaryonesource.mil/12038/MOS/Reports/2011_Demographics_Report.pdf (accessed 26 March 2018).

Drescher, Kent D., Foy, David W., Kelly, Caroline, … Litz, Brett (2011). ‘An Exploration of the Viability and Usefulness of the Construct of Moral Injury in War Veterans’. Traumatology, 17(1): 8-13.

Jinkerson, Jeremy D. (2016). ‘Defining and assessing moral injury: A syndrome perspective’. Traumatology, 22(2): 122-130.

Litz, Brett T., Stein, Nathan, Delaney, Eileen, … Maguen, Shira (2009). ‘Moral injury and moral repair in war veterans: A preliminary model and intervention strategy’. Clinical Psychological Review, 29(8): 695-706.

Nash, William P., Carper, Teresa L. Marino, Mills, Mary Alice, … and Litz, Brett T. (2013). ‘Psychometric evaluation of the Moral Injury Events Scale’. Military Medicine, 178(6): 646-652.

Roberts, D. L., Kovacich, J., & Rivers, M. (2017). The Comprehensive female soldier support model: A Delphi study. Journal of Health Care Chaplaincy. doi:10.1080/08854726.2017.1312817

Ruiz-Cantero, Maria Teresa, Vives-Cases, Carmen, Artazcoz, Lucia … Valls, Carme (2007). ‘A framework to analyse gender bias in epidemiological research’. Journal of Epidemiology & Community Health, 61(Supplement 2): ii46–ii53.

Shay, Jonathan (2014). ‘Moral Injury’. Psychoanalytic Psychology, 31(2): 182-191.

Turchik, Jessica A. and Wilson, Susan M. (2010). ‘Sexual assault in the U.S. military: A review of the literature and recommendations for the future’. Aggression and Violent Behavior, 15(4): 267-277.

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