Abstract:

Moral injury refers to the long-lasting psychological, biological, spiritual, behavioral and social impact on an individual after the exposure to morally injurious events, which entail “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” (Litz et al., 2009). Since Litz et al. (2009) redefined this concept from the perspective of psychology, moral injury has attracted extensive attention in the fields of psychology, ethics, psychiatry, and sociology. The present article reviews and summarizes the concept, relevant mechanisms, measurements, and interventions of moral injury and offer recommendations for future research. We first review the background of moral injury. Moral injury can be traced back to survivor guilt, which has long been regarded as one of the symptoms of post-traumatic stress disorder. However, Litz et al.(2009) pointed out that moral injury and post-traumatic stress disorder are two different concepts, and Shay(2014) listed the five differences between moral injury and post-traumatic stress disorder in detail. Next, we review the mechanisms of moral injury. Under the influence of individual and social factors, potentially morally injurious events that severely violate an individual's moral code can lead to cognitive dissonance and intrapsychic conflict, and eventually produce lasting shame, guilt, and anxiety. In addition, different types of potentially morally injurious events may lead to different types of moral injury, but the specific mechanism is still unclear. Self-oriented events (e.g., committing a crime, failing to prevent a crime, etc.) are more likely to result in negative internal emotions and cognitions (e.g., guilt, shame, inability to forgive oneself), whereas other-oriented events (e.g., witnessing an act of violence, betrayal by a trusted person) are more likely to lead to negative external emotions and cognitions (e.g., anger, loss of trust, inability to forgive).Third, we summarizes the existing moral injury scales, with a focus on the scope of application and each scale’s advantages and disadvantages. These scales can be divided into two categories according to their contents, with one group assessing moral injury symptoms alone, and another assessing both the moral injury events and symptoms. Researchers or clinicians can choose these scales according to their practical needs. Moreover, current interventions for moral injury include Cognitive Behavior Therapy, CBT-based Adaptive Disclosure Therapy, CPT-based Spiritually Integrated Cognitive Processing Therapy, etc. While being commonly used in the treatment of PTSD, those therapies are equally effective in treating the core symptoms of moral injury. We concluded this article with limitations of existing research and suggestions for future research. Moral injury events and moral injury outcomes need to be further distinguished, moral injury mechanisms need to be further studied, and the diagnostic criteria of moral injury need to be established. Researchers also need to pay attention to the differences of moral standards in different cultures, expand research on moral injury to more groups, and widen the application of research on moral injury.

Key words: moral injury, perspective of psychology, mechanism, measurement, intervention