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There is consensus that military personnel can encounter a far more diverse set of challenges than researchers and clinicians have historically appreciated. Moral injury (MI) represents an emerging construct to capture behavioural, social, and spiritual suffering that may transcend and overlap with mental health diagnoses (e.g., post-traumatic stress disorder and major depressive disorder). The Expressions of Moral Injury Scale-Military Version (EMIS-M) was developed to provide a reliable and valid means for assessing the warning signs of a MI in military populations. Drawing on independent samples of veterans who had served in a war-zone environment, factor analytic results revealed 2 distinct factors related to MI expressions directed at both self (9 items) and others (8 items). These subscales generated excellent internal consistency and temporal stability over a 6-month period. When compared to measures of post-traumatic stress disorder, major depressive disorder, and other theoretically relevant constructs (e.g., forgiveness, social support, moral emotions, and combat exposure), EMIS-M scores demonstrated strong convergent, divergent, and incremental validity. In addition, although structural equation modelling findings supported a possible general MI factor in Study 2, the patterns of associations for self- and other-directed expressions yielded evidence for differential validity with varying forms of forgiveness and combat exposure. As such, the EMIS-M provides a face valid, psychometrically validated tool for assessing expressions of apparent MI subtypes in research and clinical settings. Looking ahead, the EMIS-M will hopefully advance the scientific understanding of MI while supporting innovation for clinicians to tailor evidence-based treatments and/or develop novel approaches for addressing MI in their work.

Moral injury, a term coined to represent the potential negative outcomes following transgression of deeply held moral values and beliefs, has recently gained increased recognition as a major concern among military service members exposed to trauma. However, working definitions of moral injury have not yet fully clarified the mechanisms whereby violations of conscience result in these outcomes or their co-occurrence with posttraumatic stress disorder (PTSD). In this paper, advances from the field of moral psychology are used to integrate cognitive, affective, and social dimensions of the emerging moral injury construct, while also pointing to new possibilities for clinical intervention. After reviewing the salience of moral injury for military and veteran populations, the presence of negative moral emotions (e.g., guilt, anger, disgust) are examined within the context of trauma and military-related PTSD. Next, social functionalist accounts of moral emotions are used to explain the development of moral injury and are linked to potential etiologies of PTSD that emphasize both fear and nonfear emotions. Finally, the clinical importance of positive moral emotions for existing and emerging trauma-focused interventions is discussed. Future directions for research and clinical interventions are identified highlighting the importance of utilizing community support.

Debate exists regarding the most appropriate way to address moral injuries that stem from involvement in war and other military conflicts. In recent years, some researchers have suggested that existing treatments for trauma may be inadequate to address moral injury and have thus proposed novel interventions to help mitigate these concerns. In response, advocates of more traditional approaches have argued that standard trauma interventions are generally sufficient for moral injury, and investment in new interventions may be premature. This conceptual article draws from research findings and current theories of moral injury to demonstrate that there is merit on both sides of this debate, and further clarifying the types of cognitions involved in moral injury can guide effective treatment planning. In particular, the most recent diagnostic criteria for posttraumatic stress disorder is used to distinguish the objectively falsifiable descriptive cognitions often associated with trauma from the subjectively determined prescriptive cognitions that characterize moral injury. Scenarios from war zone deployments have been used to highlight the relevance of this distinction for moral injury, and a general treatment framework that shows how existing and novel interventions may complement one another is presented. Research suggestions for assessing descriptive and prescriptive cognitions in moral injury and empirically validating this treatment framework are discussed.

Although little is known about moral injury in nonmilitary populations, the COVID-19 pandemic has made it clear that moral injury's relevance extends beyond the battlefield. Health care providers are experiencing potentially morally injurious events that may violate their moral code or values, yet almost no research has been conducted on moral injury among health care providers to date. The purpose of this commentary is to describe the relevance of moral injury to health care providers and to spark a dialogue that motivates future research, prevention, and intervention.

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War zone veterans who experience posttraumatic stress disorder (PTSD) symptoms might struggle with co‐occurring cognitive, emotional, and behavioral expressions of suffering that align with conceptual definitions of moral injury (MI). However, given that PTSD is a multidimensional condition, disentangling the apparent interplay with MI may inform clinical practice and research. This study incorporated a cross‐lagged design to explore temporal associations between self‐ and other‐directed outcomes related to MI and severity of DSM‐5 PTSD symptom clusters while accounting for depressive symptoms. Drawing on the Expressions of Moral Injury Scale–Military Version in a community sample of 182 previously deployed veterans, MI‐related outcomes were linked with severity of PTSD symptom clusters at two assessments spaced apart by 6 months, rs = .58–.62. Of possible models for conceptualizing the temporal nature of these associations, structural equation modeling analyses revealed a cross‐lagged primary MI model best fit veterans’ responses. Within this model, veterans’ self‐directed MI at Time 1 predicted greater PTSD symptoms at the 6‐month follow‐up. However, an equivalent cross‐lagged path also emerged between Time 1 PTSD Cluster D symptoms and self‐directed MI at Time 2, suggesting the value of a reciprocal MI model for this symptom domain. In contrast, other‐directed outcomes of MI were not linked with PTSD in the presence of other variables. Overall, these findings support the prognostic value of assessing for MI‐related outcomes among veterans who might be struggling with PTSD symptomatology, particularly with respect to self‐directed problems associated with enduring moral distress.

Despite high levels of exposure to stress, questions remain regarding how social interactions and beliefs about emotion interact to influence posttraumatic stress disorder (PTSD) in firefighters. United States urban firefighters (N = 225) completed the Interpersonal Support Evaluation List, the Unsupportive Social Interactions Inventory, the Affective Control Scale, and the Posttraumatic Stress Disorder Checklist. Each independent variable predicted PTSD beyond variance accounted for by demographic variables. Additionally, fear of emotion emerged as the strongest individual predictor of PTSD and a moderator of the relation between social interactions and PTSD symptoms. These findings emphasize the importance of beliefs about emotion both in how these beliefs might influence the expression of PTSD symptoms, and in how the social networks of trauma survivors might buffer distress.