Trauma, Spirituality, and Moral Injury: Assessing and Addressing Moral Injury in the Context of PTSD Treatment

Abstract

Moral injury describes the psycho-socio-spiritual suffering that can follow potentially morally injurious events (PMIEs). PMIEs involve actions taken or not taken, or witnessing or being directly impacted by someone else’s actions or inactions, that violate deeply held notions of right and wrong. Moral injury is hypothesized to be a syndrome that is marked by symptoms of reexperiencing and avoidance, accompanied by moral emotions, demoralization, and social isolation or withdrawal. Further, moral injury is posited to involve questions of meaning and purpose and changes in religiosity and spirituality (R/S). This review examined current assessment tools for moral injury and described religiously and spiritually oriented treatments for moral injury and efforts to measure their impact. A few measures of exposure to PMIEs and moral injury as an outcome have been developed, primarily for active-duty service member and veteran populations. R/S therapies include an individual therapy, Spiritually-Based Cognitive Processing Therapy, and a group therapy, Building Spiritual Strength. Non-R/S therapies include adaptations to trauma-focused therapies (i.e., Cognitive Processing Therapy, Prolonged Exposure, Acceptance and Commitment Therapy) and new PMIE-focused therapies (Adaptive Disclosure, Impact of Killing). In general, there has been little psychometric research on moral injury assessment tools and few clinical trials of R/S-oriented psychotherapies. Because moral injury is an emerging clinical construct, there are few gold standard assessment tools or evidence-based treatments. Potential limitations of existing approaches and future directions for developing R/S-oriented moral injury treatments are discussed.