It is widely recognized that, along with physical and psychological injuries, war profoundly affects veterans spiritually and morally. However, research about the link between combat and changes in morality and spirituality is lacking. Moral injury is a construct that we have proposed to describe disruption in an individual’s sense of personal morality and capacity to behave in a just manner. As a first step in construct validation, we asked a diverse group of health and religious professionals with many years of service to active duty warriors and veterans to provide commentary about moral injury. Respondents were given a semistructured interview and their responses were sorted. The transcripts were used to clarify the range of potentially and morally injurious experiences in war and the lasting sequelae of these experiences. There was strong support for the usefulness of the moral injury concept; however, respondents chiefly found our working definition to be inadequate.
Bandura, A. ( 1999). Moral disengagement in the perpetration of inhumanities . Personality and Social Psychology Review, 3, 193-209.
2.
Bandura, A. ( 2002). Selective moral disengagement in the exercise of moral agency. Journal of Moral Education, 31(2), 101-119.
3.
Begic, D., & Jokic-Begic, N. (2001). Aggressive behavior in combat veterans with post-traumatic stress disorder. Military Medicine, 166, 671-676.
4.
Bras, M., Loncar, Z., Boban, M., Gregurek, R., Brajkovic, L., Tomicic, H., . . . Kaleniić, B. (2007). Self-inflicted burns in patients with chronic combat-related post-traumatic stress disorder. Collegium Antropologicum, 31, 1173-1177.
5.
Buckley, T.C., Mozley, S.L., Bedard, M.A., Dewulf, A., & Greif, J. ( 2004). Preventive health behaviors, health-risk behaviors, physical morbidity, and health-related role functioning impairment in veterans with post-traumatic stress disorder. Military Medicine, 169, 536-540.
6.
Drescher, K.D., & Foy, D.W. ( 1995). Spirituality and trauma treatment: Suggestions for including spirituality as a coping resource. National Center for Post-Traumatic Stress Disorder Clinical Quarterly, 5(1), 4-5.
7.
Fontana, A., & Rosenheck, R. ( 2004). Trauma, change in strength of religious faith, and mental health service use among veterans treated for PTSD. The Journal of Nervous and Mental Disease, 192, 579-584.
8.
Ford, J.D. ( 1999). Disorders of extreme stress following war-zone military trauma: Associated features of posttraumatic stress disorder or comorbid but distinct syndromes? Journal of Consulting and Clinical Psychology , 67(1), 3-12.
9.
Foy, D.W., Sipprelle, R.C., Rueger, D.B., & Carroll, E.M. ( 1984). Etiology of posttraumatic stress disorder in Vietnam veterans: Analysis of premilitary, military, and combat exposure influences . Journal of Consulting and Clinical Psychology, 52(1), 79-87.
10.
Grossman, D. ( 2009). On killing: The psychological cost of learning to kill in war and society (Rev. ed.). New York, NY: Back Bay Books.
11.
Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D., Cotting, D.I., & Koffman, R.L. ( 2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351(1), 13-22.
12.
Kashdan, T.B., Elhai, J.D., & Frueh, B.C. ( 2006). Anhedonia and emotional numbing in combat veterans with PTSD. Behaviour Research and Therapy, 44, 457-467.
13.
Kashdan, T.B., Elhai, J.D., & Frueh, B.C. ( 2007). Anhedonia, emotional numbing, and symptom overreporting in male veterans with PTSD. Personality and Individual Differences , 43, 725-735.
14.
Krueger, R.A. ( 1998). Focus Groups: A practical guide for applied research . Newbury Park, CA: SAGE.
15.
Kubany, E.S., Abueg, F.R., Kilauano, W.L., Manke, F.P., & Kaplan, A.S. ( 1997). Development and validation of the sources of trauma-related guilt survey-war-zone version. Journal of Traumatic Stress , 10, 235-258.
16.
Kubany, E.S., Gino, A., Denny, N.R., & Torigoe, R.Y. ( 1994). Relationship of cynical hostility and PTSD among Vietnam veterans. Journal of Traumatic Stress, 7(1), 21-31.
17.
Kulka, R.A., Schlenger, W.E., Fairbank, J.A.Hough, R.L., Jordan, B.K., Marmar, C.R., & Weiss, D.S. ( 1990). Trauma and the Vietnam generation: Report of findings from the national Vietnam veterans readjustment study. New York, NY: Brunner/Mazel.
18.
Lincoln, Y.S., & Guba, E.G. ( 1985). Naturalistic inquiry. Beverly Hills, CA: Sage.
19.
Litz, B.T., Stein, N., Delaney, E., Lebowitz, L., Nash, W.P., Silva, C., & Maguen, S. ( 2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review , 29, 695-706.
20.
Lyons, J.A. ( 1991). Self-mutilation by a man with posttraumatic stress disorder . Journal of Nervous and Mental Disease, 179, 505-507.
21.
MacNair, R. ( 2005). Perpetration-induced traumatic stress: The psychological consequences of killing. Lincoln, NE: Authors Choice Press.
22.
Maguen, S., Lucenko, B.A., Reger, M.A., Gahm, G.A., Litz, B.T., Seal, K.H., . . . Marmar, C. R. (2010). The impact of reported direct and indirect killing on mental health symptoms in Iraq War veterans. Journal of Traumatic Stress, 23(1), 86-90.
23.
Maguen, S., Metzler, T.J., Litz, B.T., Seal, K.H., Knight, S.J., & Marmar, C.R. ( 2009). The impact of killing in war on mental health symptoms and related functioning. Journal of Traumatic Stress, 22, 435-443.
24.
Mental Health Advisory Team. (2006). Operation lraqi Freedom 05-07. Retrieved http://www.armymedicine.army.mil/reports/mhat/mhat_iv/mhat-iv.cfm
25.
Pitman, R.K. ( 1990). Self-mutilation in combat-related PTSD. American Journal of psychiatry, 147(1), 123-124.
26.
Schnurr, P.P., & Spiro, A.R. ( 1999). Combat exposure, posttraumatic stress disorder symptoms, and health behaviors as predictors of self-reported physical health in older veterans. Journal of Nervous and Mental Disease, 187, 353-359.
27.
Shay, J. ( 1995). Achilles in Vietnam: Combat trauma and the undoing of character. New York, NY: Simon & Schuster.
28.
Sher, L. ( 2009). A model of suicidal behavior in war veterans with posttraumatic mood disorder. Medical Hypotheses, 73, 215-219.
29.
Singer, M. ( 2004). Shame, guilt, self-hatred and remorse in the psychotherapy of Vietnam combat veterans who committed atrocities. American Journal of Psychotherapy, 58, 377-385.
30.
Smith, T.C., Ryan, M.A., Wingard, D.L., Slymen, D.J., Sallis, J.F., & Kritz-Silverstein, D. (2008). New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: Prospective population based US military cohort study . British Medical Journal, 336, 366-371.
31.
Strauss, A.C., & Corbin, J.M. ( 1998). Basics of Qualitative Research: Second Edition: Techniques and Procedures for Developing Grounded Theory, SAGE Publications Inc. Thousand Oaks, CA.
32.
Witvliet, C.V., Phipps, K.A., Feldman, M.E., & Beckham, J.C. ( 2004). Posttraumatic mental and physical health correlates of forgiveness and religious coping in military veterans. Journal of Traumatic Stress, 17, 269-273.
