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Topic leaders

 

Shira Maguen and Sonya Norman

University of California San Francisco School of Medicine, San Francisco, USA

University of San Diego School of Medicine, San Diego, CA, USA

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Please contact Shira Maguen or Sonya Norman if you would like to initiate new projects or have other ideas about global collaboration related to moral injury. You can also directly submit your project proposal here.

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What is Moral injury?

Moral injury refers to the profound psychological distress that can arise from being exposed to various situations involving acting, failing to act, or witnessing events that go against personal or collective core beliefs or expectations (e.g. Litz et al., 2009, Griffin et al, 2019; Ter Heide & Olff, 2023, Schnyder, 2024). Moral injury involves both an exposure to a potentially morally injurious event during which individuals experience or witness a transgression, as well as resulting symptoms of intense self-condemnation, spiritual struggles, and internal conflict regarding the moral implications of their actions. Experiencing moral injury carries significant emotional risks, as individuals may perceive their transgressions as irreparable, resulting in feelings of shame, guilt, despair, and loss of morale. Research suggests that moral injury is linked to cognitive, emotional, and behavioral changes, including social withdrawal, suicide behaviors, burnout, and psychiatric disorders such as depression and PTSD.​​

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Projects

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1. Understanding Prevalence, Presentation, Prevention and Treatment of Moral Injury in Populations and Cultures Across the Globe

 

Project group

PIs: Brandon Griffin,  Shira Maguen, Sonya Norman

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Background

Moral injury impacts people across the globe. While most moral injury research has focused on combat veterans, recent studies demonstrate that moral injury can impact healthcare workers, first responders, child protection officers, police, forcibly displaced persons such as refugees and asylum seekers, and civilians impacted by war (Schnyder, 2024). There is a need to understand the prevalence and impacts of moral injury across populations and cultures, including a need to understand which features of moral injury remain stable and which may present differently across populations and cultures. Such knowledge is critical to effective and culturally sensitive prevention and intervention efforts. The recently developed Moral Injury and Distress Scale (MIDS) is ideal for such efforts because of its strong psychometric properties (including easy sum score due to single factor structure), because it assesses both exposure to potentially morally injurious events and related moral injury symptoms, because it has been validated with several at-risk populations, and because it is designed to measure change over time.

 

Aims and method

The aim of this project is to work with international collaborators through the Global Collaboration on Traumatic Stress to translate the MIDS into different languages to collect data on prevalence and presentations of moral injury across populations and cultures. Projects are underway or completed to translate the MIDS into Portuguese, Korean, and Japanese. We invite potential collaborators interested in collecting moral injury data in their populations or cultures of interest. We will work with you to translate and validate the MIDS using World Health Organization best practices with the ultimate goal of being able to look at moral injury data across countries, populations, and cultures.

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2. Translation and Validation of Moral Injury Scales in Brazil

 

Project group

PI: Bruno Messina Coimbra

Project group: Brendon Griffin, Chris Hoeboer, Shira Maguen, Andrea Feijo Mello, Marcelo Feijo Mello, Sonya Norman, Miranda Olff

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Background

The COVID-19 pandemic has exacerbated ethical dilemmas faced by healthcare workers globally, particularly in developing countries where resource scarcity is prevalent (Coimbra et al., 2024). This situation has contributed to the emergence of significant symptoms of moral injury among healthcare professionals. However, it is worth noting that the moral injury literature currently lacks sufficient representation from these countries.

 

Aims and method

As evidence from developing countries may help to bring more insight into the moral challenges imposed on healthcare workers globally, we aim to introduce moral injury studies in Brazil by translating and validating two scales to Brazilian Portuguese: the Moral Injury Symptom Scale (MISS-HP) and the Moral Injury Distress Scale (MIDS). Given the significant emotional burden experienced by Brazilian healthcare workers during the COVID-19 pandemic, this research holds particular relevance.

To ensure the validity of both the MISS-HP and the MIDS, we will follow the four-step guidelines outlined by the World Health Organization for scale translation and validation. Following this process, we intend to promote the study through social media platforms and recruit 300 healthcare workers in Brazil to participate in an online survey. To establish convergent and divergent validity, we

will employ scales that measure depression, anxiety, PTSD, burnout, and religious conflicts. Additionally, the construct validity of the Brazilian versions of the MISS-HP and the MIDS will be assessed using exploratory factor analysis. By undertaking these steps, we expect to contribute valuable insights into moral injury experienced by healthcare workers in Brazil.

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3. Moral Injury Instruments in Portugal: Translation, Cultural Adaptation and Psychometric Properties

 

Project Group

PI: Mariana Gonçalves (PhD) & Ângela Maia (PhD)

Project Group:

Ana Lúcia Silva, PhD; Joana Neiva, Master; Joana Matos, Master; Cristiana Santos, Master; Rute Pereira, Master

Institution: Psychology Research Center, School of Psychology, University of Minho, Braga, Portugal

 

Background

Moral Injury is an enduring experience of negative moral emotions, such as guilt, shame, contempt, and anger. It arises when deeply held or commonly shared moral values are violated, suppressed, or betrayed. Originally observed in military personnel and veterans, moral injury often involves self-condemnation and a profound loss of faith in religious, moral, and societal institutions. These morally injurious events can happen in various contexts, including the military, healthcare, law enforcement, emergency, and many others, but also in persons that were exposed to trauma. While moral injury may coexist with Post-traumatic Stress-Disorder (PTSD), it is distinct because it doesn't stem from our body or mind's reaction to traumatic stress but rather revolves around a deep moral discomfort concerning our individual and collective actions, inactions, and fundamental values.

 

Aims and method

Aims: to translate, culturally adapt and analyse the psychometric properties of the Moral Injury instruments to Portuguese populations. Specifically, we will validate the Moral Injury Events Scale (MIES), the Expressions of Moral Injury Scale (EMIS) and the Moral Injury and Distress Scale (MIDS).

Sample: 700 civilians and professionals, aged 18 or higher, gender inclusive. We will include professional from different areas: health (e.g., doctors, nurses, psychologists), social (e.g., social workers), justice (e.g., law enforcement professionals, lawyers, judges) frontline (e.g., emergency, firefighters), and journalists.

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4. Moral Trauma and Moral Healing in Ukrainian Combat and Civilian Populations

From Neurocognitive and Psychological Assessment to Preventative and Promotional Interventions

 

Project leader

Larysa Zasiekina, Lesya Ukrainka Volyn National University,  & Department of Psychology, University of Cambridge 

(lz464@cam.ac.uk).

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Project group

Serhii Zasiekin, Lesya Ukrainka Volyn National University, University College London, School of Slavonic and East European Studies, 

Illia Kuznietsov, College of Health and Human Sciences, Department of Psychological Sciences, Laboratory of Computational Cognitive Neuroscience, Purdue University

Iryna Hlova, Department of General and Clinical Psychology, Lesya Ukrainka Volyn National University,

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Background

Little is known about moral trauma and moral healing in Ukrainian combat and civilian populations, both with regard to neurocognitive and psychological assessment as well as what preventative and promotional Interventions nay need to be developed.

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Aims

1. To examine moral injury and associated mental health symptoms (PTSD, depression and anxiety) in Ukrainian combat and civilian populations.

2. To identify neural correlates of moral injury and compare them with neural correlates of PTSD.

3. To develop preventative and promotional interventions for moral healing after military trauma. 

The following set of research questions were formulated: 

(RQ1) Are there significant differences in moral injury, PTSD, depression and anxiety symptoms between active-duty soldiers and the civilian population?

(RQ2) Are there significant differences in neural correlates of war-related moral injury and PTSD?

(RQ3) Are there gender effects in the two groups (active soldiers and civilian students) in relation to moral injury and associated mental health symptoms? 

(RQ4) Is a family history of genocide associated with moral injury, PTSD, depression and anxiety?_ 

(RQ5) Is the moral injury a predictor of PTSD in both groups?

 

The cultural adaptation and psychometric standardization of the MISS-M-SF questionnaire (the first Ukrainian-language diagnostic tool for assessing moral injury) were carried out during the project. The study has important theoretical and practical implications. It provides explicit criteria for distinguishing between moral injury and PTSD and developing the first Ukrainian self-care mobile application “Moral Injury Coach”.

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Please find the Ukrainian version of Moral Injury Symptoms Scale-Short Form (MISS-SF) in:

Zasiekina, L., & Kozihora, M. . (2022). Cross-Cultural Adaptation and Psychometric Properties of Moral Injury Symptoms Scale. Psychological Prospects Journal, 39, 139–152. https://doi.org/10.29038/2227-1376-2022-39-zas

 

Funding: The project is funded by Ministry of Education and Science of Ukraine, 0122U000945 (2022-2025).

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