Staff Perspective: Identification and Assessment of Moral Injury
To facilitate a discussion about how to identify and assess for moral injury, let’s review the account below written by Ms. Tessa Poppe, who served in the Army National Guard as a Military Police Officer for seven years and was deployed to Afghanistan in 2010. It’s titled, When the Hardest Thing is Doing Nothing: Moral Injury Caused by Inaction in War and appeared in Foreign Policy on 12 June 2015. Through her narrative, Ms. Poppe paints a picture of a moral dilemma when she felt paralyzed about what to do while deployed and the inner turmoil associated with it.
One morning I stood guard at the edge of our camp in Kunar, Province, Afghanistan. Scanning the area below my position I noticed a boy about seven years old and a young man, maybe seventeen or eighteen, walking by a nearby house. My instincts told me something was wrong so I raised my rifle to study them through my scope. I noticed the little boy had bare feet, I’ll never forget that. It was morning still, but the heat was rising, the humidity stuck to my skin. I watched the young man lead the boy to a set of steps outside the house. I couldn’t tell at first why or what was happening, my mind suspended in disbelief, but soon I realized the young man was raping the seven-year-old boy. I dropped my rifle to my side, my heart racing—confused, disgusted, and torn. But suddenly I raised it again, my index finger quivering on the trigger. I exhaled, focusing on the target like we were taught to do. I don’t know how long I stood there, locked on his chest with my rifle, contemplating taking a young man’s life. I wanted to kill him. But I thought—What if they’re brothers? What will the blowback be? Will I go to prison? Those questions lingered for what seemed like hours. A sickening feeling rose from somewhere deep in my stomach, up into my throat and rested there. The knot would stay for days, weeks, months, years. I didn’t shoot the man, really a boy himself, but neither did I shout or scream. I did nothing.
This testimonial exemplifies how inaction or failure to act in war may lead to moral injury – an individual need not perpetrate a violent act for moral injury to develop. Witnessing a horrible situation that yanks at a person’s soul—in which a Service member may have to make a split second decision whether to intervene or not when both choices have negative consequences —can contribute to long-lasting anguish and self recrimination for some individuals. As one military physician, Dr. Wayne Jonas, so aptly explains: “Most people enter military service with the fundamental sense that they are good people and that they are doing this for good purposes… But things happen in war that are irreconcilable with the idea of goodness and benevolence, creating real cognitive dissonance. I’m a good person and yet I’ve done bad things” (Wood, 2014).
With the increased focus on moral injury over the past few years, including testimonials by individuals like Ms. Poppe, clinicians need to be able to identify military clients who may be struggling with moral injury. This will enable them to provide the most helpful and appropriate interventions. In the article, Defining and Assessing Moral Injury: A Syndrome Perspective, Jinkerson (2016) provides an overview of moral injury, including types of potentially morally injurious events, symptoms of it, how it differs from PTSD, and guidelines for assessing it. He updates the definition, describing it as moral injury syndrome, which he regards as “a particular type of trauma characterized by guilt, existential crisis and loss of trust that may develop following a perceived violation (p. 122). More specifically, he delineates core symptoms of moral injury syndrome, which include guilt, shame, spiritual conflict or a loss of trust, and secondary symptoms, such as depression, anxiety, anger, intrusive thoughts and images, isolation, substance use problems, harming oneself, and feelings of demoralization.
Jinkerson proposes that for an individual to be identified with moral injury syndrome, he or she must: (1) show a history of exposure to a morally injurious event and (2) experience guilt plus at least two other symptoms (that may be core or secondary). To this end, he recommends that clinicians first assess if their client has experienced morally injurious events by using the Moral Injury Questionnaire-Military Version (MIQ-M). Another assessment is the Moral Injury Event Scale (MIES), although Mr. Jinkerson finds this measure more general and face valid and thus prefers the MIQ-M.
According to Jinkerson (2016), if a client endorses a history of exposure to morally injurious events, clinicians should proceed to give a relatively brief battery of self-report measures for individual symptoms of moral injury since there currently is no validated instrument that captures the full syndrome. Examples of measures that he suggests are the Trauma Related Grief Inventory (TRGI); Meaning in Life Questionnaire (MLQ); Trustworthiness & Goodness of People (TGP) Scale from the World Assumptions Questionnaire (WAQ); Trauma-Related Shame Inventory (TRSI); Posttraumatic Stress Disorder Checklist-5 (PCL-5), Alcohol Use Disorders Identification Test-C (AUDIT-C); Social Functioning Questionnaire (SFQ) and/or Patient Health Questionnaire (PHQ-9).
Consistent with Jinkerson, Frankfurt & Frazier (2016) raise cautions about assessing for moral injury in their article, A Review of Research on Moral Injury in Combat Veterans. They underscore that more research is needed on moral injury overall because the concept is complicated by unclear definitions, causes, processes, and outcomes. They advise that measuring an individual’s exposure to what they call “transgressive acts” (i.e., experiences in which accepted boundaries or behavior are violated) is distinct from measuring the effects or outcomes (i.e., symptoms or reactions) of that exposure. In other words, evaluating the cause or transgressive act and the effect or outcome of it in the same assessment item can suggest connections between the two that may not be valid. For example, merely because a person scores high on exposure to transgressive acts does not mean he or she has moral injury. Think about trauma exposure and PTSD. Just because an individual has experienced several traumatic events does not mean they have developed PTSD.
Similar to Jinkerson, these researchers recommend the MIQ-M over the MIES because it poses more specific questions and doesn’t blur the symptoms of moral injury with the morally injurious events themselves. They also draw attention to the ongoing debate about what is considered “transgressive,” noting that the prevalence of transgressive acts hasn’t been systematically studied in war Veteran cohorts. They further suggest that clinicians distinguish committing transgressive acts from witnessing them separately when assessing for moral injury. In addition to these suggestions, below are questions for inviting a conversation about moral injury with clients. They were developed by CDP faculty based on their clinical experiences; they haven’t been empirically validated.
- When I talk to other Service members, they often describe losses they experienced while in theater. Did you have similar losses?
- Do you have nagging thoughts or regrets about your deployment or joining the military that you can’t seem to shake off?
- Have you begun to rethink your beliefs about spirituality or religion since returning from deployment?
- Have you been questioning decisions or events that happened in theater?
- Are there aspects of your deployment experience that are difficult or troubling for you to share with others?
- Often Service members report things happened while they were deployed that don’t match up with how they think or feel about things. Did you have an experience like that?
- Some Service members describe feeling a sense of blame or guilt or shame over something they did or didn’t do when deployed. Can you relate to this?
So the next time you meet with a military client who may have encountered an experience like the one Ms.Poppe described, consider this discussion about moral injury. Open the door for them to talk about situations they may have participated in, witnessed or experienced which may have transgressed or even betrayed their ethical or moral beliefs. Inquire how these events may have impacted them – their life, their views of the world, their emotions and behaviors, and their trust in themselves and others. Keep in mind that the impact could range on a continuum—from not at all or very little to severely or overwhelmingly such that they feel like their underlying character or soul has been broken. Think about using some of the tools mentioned here to begin to validate and help these clients.
References
Frankfurt, S., & Frazier, P. (2016). A review of research on moral injury in combat veterans. Military Psychology, 28, 318 –330.
Jinkerson, J. (2016). Defining and assessing moral injury: A syndrome perspective. Traumatology, 22(2), 122-130.
Poppe, T. (2015, June 12). When the hardest thing is doing nothing: Moral injury caused by inaction in war. Foreign Policy. T. Ricks (Ed). Retrieved from http://foreignpolicy.com/2015/06/12/when-the-hardest-thing-is-doing-nothing-moral-injury-caused-by-inaction-in-war/
Wood, D. (2014, March 18). The grunts: Damned if they kill, damned if they don’t. Huffington Post. Retrieved from: http://projects.huffingtonpost.com/moral-injury/the-grunts
To facilitate a discussion about how to identify and assess for moral injury, let’s review the account below written by Ms. Tessa Poppe, who served in the Army National Guard as a Military Police Officer for seven years and was deployed to Afghanistan in 2010. It’s titled, When the Hardest Thing is Doing Nothing: Moral Injury Caused by Inaction in War and appeared in Foreign Policy on 12 June 2015. Through her narrative, Ms. Poppe paints a picture of a moral dilemma when she felt paralyzed about what to do while deployed and the inner turmoil associated with it.
One morning I stood guard at the edge of our camp in Kunar, Province, Afghanistan. Scanning the area below my position I noticed a boy about seven years old and a young man, maybe seventeen or eighteen, walking by a nearby house. My instincts told me something was wrong so I raised my rifle to study them through my scope. I noticed the little boy had bare feet, I’ll never forget that. It was morning still, but the heat was rising, the humidity stuck to my skin. I watched the young man lead the boy to a set of steps outside the house. I couldn’t tell at first why or what was happening, my mind suspended in disbelief, but soon I realized the young man was raping the seven-year-old boy. I dropped my rifle to my side, my heart racing—confused, disgusted, and torn. But suddenly I raised it again, my index finger quivering on the trigger. I exhaled, focusing on the target like we were taught to do. I don’t know how long I stood there, locked on his chest with my rifle, contemplating taking a young man’s life. I wanted to kill him. But I thought—What if they’re brothers? What will the blowback be? Will I go to prison? Those questions lingered for what seemed like hours. A sickening feeling rose from somewhere deep in my stomach, up into my throat and rested there. The knot would stay for days, weeks, months, years. I didn’t shoot the man, really a boy himself, but neither did I shout or scream. I did nothing.
This testimonial exemplifies how inaction or failure to act in war may lead to moral injury – an individual need not perpetrate a violent act for moral injury to develop. Witnessing a horrible situation that yanks at a person’s soul—in which a Service member may have to make a split second decision whether to intervene or not when both choices have negative consequences —can contribute to long-lasting anguish and self recrimination for some individuals. As one military physician, Dr. Wayne Jonas, so aptly explains: “Most people enter military service with the fundamental sense that they are good people and that they are doing this for good purposes… But things happen in war that are irreconcilable with the idea of goodness and benevolence, creating real cognitive dissonance. I’m a good person and yet I’ve done bad things” (Wood, 2014).
With the increased focus on moral injury over the past few years, including testimonials by individuals like Ms. Poppe, clinicians need to be able to identify military clients who may be struggling with moral injury. This will enable them to provide the most helpful and appropriate interventions. In the article, Defining and Assessing Moral Injury: A Syndrome Perspective, Jinkerson (2016) provides an overview of moral injury, including types of potentially morally injurious events, symptoms of it, how it differs from PTSD, and guidelines for assessing it. He updates the definition, describing it as moral injury syndrome, which he regards as “a particular type of trauma characterized by guilt, existential crisis and loss of trust that may develop following a perceived violation (p. 122). More specifically, he delineates core symptoms of moral injury syndrome, which include guilt, shame, spiritual conflict or a loss of trust, and secondary symptoms, such as depression, anxiety, anger, intrusive thoughts and images, isolation, substance use problems, harming oneself, and feelings of demoralization.
Jinkerson proposes that for an individual to be identified with moral injury syndrome, he or she must: (1) show a history of exposure to a morally injurious event and (2) experience guilt plus at least two other symptoms (that may be core or secondary). To this end, he recommends that clinicians first assess if their client has experienced morally injurious events by using the Moral Injury Questionnaire-Military Version (MIQ-M). Another assessment is the Moral Injury Event Scale (MIES), although Mr. Jinkerson finds this measure more general and face valid and thus prefers the MIQ-M.
According to Jinkerson (2016), if a client endorses a history of exposure to morally injurious events, clinicians should proceed to give a relatively brief battery of self-report measures for individual symptoms of moral injury since there currently is no validated instrument that captures the full syndrome. Examples of measures that he suggests are the Trauma Related Grief Inventory (TRGI); Meaning in Life Questionnaire (MLQ); Trustworthiness & Goodness of People (TGP) Scale from the World Assumptions Questionnaire (WAQ); Trauma-Related Shame Inventory (TRSI); Posttraumatic Stress Disorder Checklist-5 (PCL-5), Alcohol Use Disorders Identification Test-C (AUDIT-C); Social Functioning Questionnaire (SFQ) and/or Patient Health Questionnaire (PHQ-9).
Consistent with Jinkerson, Frankfurt & Frazier (2016) raise cautions about assessing for moral injury in their article, A Review of Research on Moral Injury in Combat Veterans. They underscore that more research is needed on moral injury overall because the concept is complicated by unclear definitions, causes, processes, and outcomes. They advise that measuring an individual’s exposure to what they call “transgressive acts” (i.e., experiences in which accepted boundaries or behavior are violated) is distinct from measuring the effects or outcomes (i.e., symptoms or reactions) of that exposure. In other words, evaluating the cause or transgressive act and the effect or outcome of it in the same assessment item can suggest connections between the two that may not be valid. For example, merely because a person scores high on exposure to transgressive acts does not mean he or she has moral injury. Think about trauma exposure and PTSD. Just because an individual has experienced several traumatic events does not mean they have developed PTSD.
Similar to Jinkerson, these researchers recommend the MIQ-M over the MIES because it poses more specific questions and doesn’t blur the symptoms of moral injury with the morally injurious events themselves. They also draw attention to the ongoing debate about what is considered “transgressive,” noting that the prevalence of transgressive acts hasn’t been systematically studied in war Veteran cohorts. They further suggest that clinicians distinguish committing transgressive acts from witnessing them separately when assessing for moral injury. In addition to these suggestions, below are questions for inviting a conversation about moral injury with clients. They were developed by CDP faculty based on their clinical experiences; they haven’t been empirically validated.
- When I talk to other Service members, they often describe losses they experienced while in theater. Did you have similar losses?
- Do you have nagging thoughts or regrets about your deployment or joining the military that you can’t seem to shake off?
- Have you begun to rethink your beliefs about spirituality or religion since returning from deployment?
- Have you been questioning decisions or events that happened in theater?
- Are there aspects of your deployment experience that are difficult or troubling for you to share with others?
- Often Service members report things happened while they were deployed that don’t match up with how they think or feel about things. Did you have an experience like that?
- Some Service members describe feeling a sense of blame or guilt or shame over something they did or didn’t do when deployed. Can you relate to this?
So the next time you meet with a military client who may have encountered an experience like the one Ms.Poppe described, consider this discussion about moral injury. Open the door for them to talk about situations they may have participated in, witnessed or experienced which may have transgressed or even betrayed their ethical or moral beliefs. Inquire how these events may have impacted them – their life, their views of the world, their emotions and behaviors, and their trust in themselves and others. Keep in mind that the impact could range on a continuum—from not at all or very little to severely or overwhelmingly such that they feel like their underlying character or soul has been broken. Think about using some of the tools mentioned here to begin to validate and help these clients.
References
Frankfurt, S., & Frazier, P. (2016). A review of research on moral injury in combat veterans. Military Psychology, 28, 318 –330.
Jinkerson, J. (2016). Defining and assessing moral injury: A syndrome perspective. Traumatology, 22(2), 122-130.
Poppe, T. (2015, June 12). When the hardest thing is doing nothing: Moral injury caused by inaction in war. Foreign Policy. T. Ricks (Ed). Retrieved from http://foreignpolicy.com/2015/06/12/when-the-hardest-thing-is-doing-nothing-moral-injury-caused-by-inaction-in-war/
Wood, D. (2014, March 18). The grunts: Damned if they kill, damned if they don’t. Huffington Post. Retrieved from: http://projects.huffingtonpost.com/moral-injury/the-grunts