Within the past decade, the emerging field of moral injury has focused mostly on the clinical dimension of a traumatic event (Griffin et al., Journal of Traumatic Stress, 2019, 32, p. 350). This article will present a character dimension of moral injury and briefly introduce a dual pathway model of moral injury reflecting clinical and character dimensions. The investigation of the character domain borrows from the theoretical and empirical bases of moral philosophy, moral psychology, character psychology, and social psychology. Hence, this multidisciplinary understanding of moral injury encompasses: (a) moral failure, or the failure to adhere to a virtue as prescribed by a group or institution, (b) suffering or death as a direct result of moral failure, (c) unethical marking on a person's character, and (d) experience of identity negotiation between the real self and the undesired self. This character framework attempts to advance a broader theoretical foundation for moral injury that has wider applicability to the varieties of human experience, and reflects a deeper understanding of the self-concept that is not defined by and does not necessarily reflect clinical impairments. Public Significance StatementThis article discusses how moral injury arises when the experience of suffering caused by moral failure (i.e., the lack of human goodness) is reflected onto one's character and identity. Moral injury is defined as a less than virtuous state of being (in the Aristotelian context of character and identity) arising from suffering or even death brought about by one's own or another person's moral failure.

Service members who transition out of the military often face substantial challenges during their transition to civilian life. Leaving military service requires establishing a new community as well as sense of connectedness to that community. Little is known about how social connectedness may be related to other prominent transition outcomes, particularly symptoms of posttraumatic stress disorder (PTSD). The purpose of this study was to explore the role of social connectedness in the development of PTSD, as well as its relationship to the known risk factors of combat exposure and discharge status. Data used were drawn from a needs assessment survey of 722 veterans. A path model was specified to test direct and indirect effects of combat experiences, non-honorable discharge status, and social connectedness on PTSD symptoms. Results demonstrated positive direct effects for combat experiences and non-honorable discharge status on PTSD symptoms while social connectedness demonstrated a negative direct effect. Both combat experiences and non-honorable discharge status demonstrated negative direct effects on social connectedness and indirect on PTSD through the social connectedness pathway. Study findings indicate social connectedness may be an important factor related to PTSD in veterans as well as an intervention point for mitigating risk related to combat exposure and discharge status.

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Objective The general medical health of individuals with serious mental illnesses is compromised relative to those without serious mental illnesses. To address this health disparity, numerous integrated care strategies are being employed from the system level to the level of individual patients. However, self-management of health care, a strategy considered an integral aspect of typical care, has been infrequently included in interventions for this population. Despite reservations about the capacity of those with serious mental illnesses to self-manage health care, a subset of new interventions focused on general medical health in this population has tested whether models including self-management strategies have empirical support. To understand whether these models are supported, the authors reviewed the evidence for self-management models. Methods This systematic review examined collaborative and integrated care models that include self-management components for individuals with serious mental illnesses. Results Across the 14 studies identified in this review, promising evidence was found that individuals with serious mental health issues can collaborate with health professionals or be trained to self-manage their health and health care. The evidence supports the use of mental health peers or professional staff to implement health care interventions. However, the substantial heterogeneity in study design, types of training, and examined outcomes limited conclusions about the comparative effectiveness of existing studies. Conclusions This review found preliminary support that self-management interventions targeting the general medical health of those with serious mental illnesses are efficacious, but future work is needed to determine what elements of training or skills lead to the most salient changes.

Moral injury has emerged as a topic of significant research and clinical interest over the last decade. However, much work remains to be done to comprehensively define the moral injury construct, with implications for understanding the etiology and maintenance of moral injury, its symptoms, associations with and distinctions from traumatic illness, and treatment approaches. We provide a brief overview of the existing moral injury literature and introduce a novel dual process model (DPM) of moral injury and traumatic illness. The DPM posits an event exposure which may satisfy DSM-5 posttraumatic stress disorder (PTSD) criterion A, potential morally injurious event (PMIE) criteria, or both, followed by individual role appraisal as a perpetrator through action or inaction, a witness, a victim, or a combination of the these. Role appraisal influences symptoms and processes across biological, psychological, behavioral, social, spiritual/religious, as well as values, character, and identity domains to support a label of traumatic illness, moral injury, or both. The DPM provides a flexible analytical framework for evaluating symptoms associated with moral injury and traumatic stress and has important implications for treatment. The most thoroughly reviewed evidence-based interventions for traumatic stress hinge on exposure and habituation mechanisms to manage dysregulation of fear and memory systems, but these mechanisms often do not address core domains of moral injury identified in the DPM, including spiritual, religious, values, character, and identity domains as these exist largely outside of the putative fear network. We provide brief vignettes to illustrate the practical application of the DPM and argue that adjunct and stand-alone approaches which address values and character domains, leveraging principles of Stoicism, non-judgment of experience, acceptance, and values-oriented action, are more likely than traditional trauma treatment approaches to positively affect moral injury symptoms.