Putting moral injury on the map: Studying moral injury in diverse populations and contexts.





Assigned to session

0.07 Theaterzaal, 29-09-2023, 13:30 - 14:45

Field of research

Police, military & emergency services, health care personnel
Complex PTSD, comorbidities, grief

Overview of symposium

Moral injury is a relatively new concept in the field of psychotraumatology that refers to persistent,  psychological, social and spiritual suffering after involvement in acts that transgress deeply held moral beliefs and expectations. While the concept originates from a military setting, more recently the study of moral injury is broadening to include other populations exposed to violence or high stakes situations, such as first responders, healthcare workers and refugees. In this symposium, three [or four] research programs for moral injury are outlined that focus on assessment, prevention and treatment of moral injury in military veterans, police officers and healthcare workers.


No participants found...

Moral injury in context: Organizational and societal aspects in the development of moral injury in police officers and military personnel

PhD Tine Molendijk



The phenomenon of moral injury in military and police personnel draws attention not only to the individual moral dimensions of psychological suffering within organizations but also to contextual aspects. This contribution discusses qualitative, ethnographic research on moral injury in the Dutch military and police. Military and police personnel can experience tragic moral dilemmas, perpetrate or fail to prevent serious violations of their moral expectations and beliefs, and experience senselessness, which in high-stakes situations may give rise to strong feelings of guilt, shame, anger as well as profound moral disorientation. In these experiences of moral injury, political practices, such as political decision-making and framing, and public opinion may play an important role. One crucial implication is that recognizing the pivotal role of contextual factors in moral injury should lead us to develop interventions that do not solely place the burden of moral resilience on individual military and police personnel, but also focus on addressing these contextual factors.


Tine Molendijk

Moral Injury and Mental Health among Healthcare Workers in the COVID-19 Era

PhD Bruno Messina Coimbra



During the COVID-19 pandemic, healthcare workers (HCWs) may have been challenged to face exceptional ethical dilemmas that are morally stressful, such as whom to assign a ventilator or a bed in an intensive care unit, potentially generating significant levels of moral injury (MI). Resource scarcity may have aggravated these ethical dilemmas in developing countries, but these countries are underrepresented in MI literature. As evidence from developing countries may help to bring more insight into the moral challenges imposed on HCWs globally, we are introducing MI studies in Brazil by validating two scales to Brazilian Portuguese: the Moral Injury Symptom Scale (MISS-HP) and the Moral Injury Distress Scale (MIDS, ongoing project). We also performed a meta-analysis of MI and symptoms of posttraumatic stress disorder, anxiety, depression, burnout, and suicidality among active HCWs during the COVID-19 pandemic. We retrieved 26 articles from 12 countries, representing 27,699 individuals. We found an association between MI and all investigated mental health problems (rs=0.31 to 0.41, all ps<.0001). A higher percentage of nurses was associated with a stronger relationship between MI and depressive and anxiety symptoms. Our findings underscore the need to mitigate the effect of potentially morally injurious events on the mental health of HCWs.


Bruno Messina Coimbra

Assessing and treating moral injury in US military veterans.

PhD Shira Maguen



Veterans with moral injury are at increased risk for PTSD, alcohol abuse, suicide, and functional difficulties. In this talk, we will review a new measure for moral injury called the Moral Injury and Distress Scale (MIDS) and discuss research on a moral injury treatment for veterans. First, our goal was to develop and test the MIDS, the first measure to evaluate exposure to potentially morally injurious events (PMIEs) and possible emotional, cognitive, behavioral, social, and spiritual sequelae, across three groups at high risk for MI: military veterans, healthcare workers, and first responders (N = 953). The MIDS demonstrated excellent internal consistency and moderate-to-high two-week stability. Convergent validity of putative indicators (e.g., guilt, shame) were positive and large in magnitude (r = .70-.71, p < .001), as were correlations with PTSD, depressive, and insomnia symptoms (r = .50-.66, p < .001). We will also discuss both a prior pilot trial as well as an ongoing muti-site trial of Impact of Killing (IOK). IOK is an individual therapy treatment lasting 90 minutes focused on key themes including moral injury, loss, and self-forgiveness. In an intent-to-treat analysis, we found that compared to controls, the IOK group experienced significant improvements in general psychiatric symptoms, PTSD, depression, anxiety, phobic anxiety, obsessive compulsive symptoms, and avoidance. The IOK group also experienced significant improvements in functional measures (e.g., more partner intimacy); and gains in self-forgiveness, self-compassion, and self-acceptance. These results provide evidence that veterans can benefit from a treatment focused on the impact of killing.  


Shira Maguen