A new measure designed to identify people experiencing moral injury and to help ensure they receive the support they need has been developed by psychologists at the University of Bath and is now ready for use by healthcare providers.
The assessment tool, described in the European Journal of Trauma & Dissociation, is the first to be specifically developed and validated for use in UK populations. It is designed to help clinicians and researchers spot individuals affected by moral injury, monitor changes in symptoms over time, and evaluate treatment outcomes.
Moral injury refers to the profound psychological, emotional and social distress that can occur after experiences that violate a person's moral or ethical beliefs.
These experiences – known as potentially morally injurious events (PMIEs) – may involve actions taken, actions not taken, or perceived betrayal by trusted individuals or organisations. People affected by moral injury can experience intense feelings of guilt, shame, anger and blame, alongside difficulties that may impact their relationships, wellbeing and mental health.
Existing measures of moral injury, which are widely regarded as flawed or problematic, have largely been developed in US military populations and later adapted for wider use, raising questions about their suitability for civilian populations.
The new measure, called the Moral Injury Scale (MORIS), was developed by a team led by Dr Victoria Williamson from the Department of Psychology at Bath, and provides the most comprehensive assessment currently available. It does this by measuring exposure to potentially morally injurious events, moral injury-related distress, and associated risk and protective factors.
A public health concern
Moral injury is increasingly recognised as a public health concern and has been identified among a wide range of groups, including healthcare workers, military personnel, first responders, military veterans and others exposed to ethically challenging situations.
While it is not itself a mental health disorder, people who develop moral injury are at risk of experiencing mental health conditions such as depression, anxiety, post-traumatic stress disorder (PTSD), suicidality and alcohol misuse.
Cases of moral injury can be difficult to detect and treat. Healthcare professionals have reported that it is often missed during routine assessments, increasing the risk that people receive interventions that do not adequately address the root causes of their distress.
The MORIS is a self-report measure developed and validated in UK samples. It separately assesses exposure to morally injurious events and their psychological impact, allowing clinicians and researchers to distinguish between exposure to morally injurious events and the distress associated with them.
The researchers have also identified a potential cut-off score for moral injury-related distress, which could help practitioners determine when someone may require additional support – an issue that has previously posed significant challenges for the field.
The team anticipates that the measure will be adopted by both researchers and healthcare providers, including services such as the NHS.
Evidence supporting use of the measure comes from a study involving UK adults who have experienced morally or psychologically distressing events. In the validation study, a reduced version of MORIS was administered to an independent sample of 382 participants, with analyses providing preliminary evidence for the reliability and validity of the scale's distress subscale.
Dr Williamson said: "When we first began researching moral injury in 2016, there were very few measurement tools available and those that did exist had significant methodological limitations. Reaching this point has taken many years of work, so this is a really exciting milestone.
"MORIS gives researchers and clinicians a much more robust way to assess moral injury and flag people who may be struggling. We hope it will help advance both research and clinical practice in this growing area."
The research team will now use MORIS in clinical trials to evaluate treatments for moral injury. The assessment tool is also currently undergoing validation in Turkey. If successful, it would become the first validated moral injury measure available for use in a non-Western context.
Study co-author Neil Greenberg, professor of Defence Mental Health at King's College London and a former UK Armed Forces psychiatrist and researcher with more than 23 years of service, said “If we’re able to identify moral injury early on, and intervene, we may be able to prevent the onset of formal mental health disorders which should help military personnel and higher risk workers live fulfilling and productive lives.
“Morally injured people often experience disturbed interpersonal relationships, so being able to deliver effective interventions earlier should also help family members and work colleagues as well.
“The use of the MORIS should enable earlier identification of those with moral injuries, allowing evidence-based interventions to be used to return them to good health and ensure they remain productive and operationally effective.”