Development and evaluation of the Expressions of Moral Injury Scale—Military Version

Abstract

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.

Military Culture and Post-Military Transitioning Among Veterans: A Qualitative Analysis

“…Furthermore, Shay (1995Shay ( , 2014 has contributed a three-part definition of MIEs, suggesting these experiences consist of "(a) a betrayal of 'what's right'; (b) by someone who holds legitimate authority; (c) in a high-stakes situation" (2014, p. 183). Evidence suggests MIEs can lead to intra-and interpersonal distress (dysphoric moral emotions [e.g., guilt, shame, and anger] and negative cognitions [e.g., self-blame, distrust of others]; Currier et al, 2018) and impair psychosocial functioning among veterans (e.g., Farnsworth et al, 2014;Jinkerson, 2016;Kopacz et al, 2016). Veterans struggling from experiences that conflicted with deeply held values and beliefs may be reluctant to engage in help-seeking behaviors due to perceiving themselves as undeserving of "getting better" (shame-based cognitions) or mistrust of authority (e.g., US Department of Veterans Affairs, healthcare providers).…”

Veterans’ perspectives on discussing moral injury in the context of evidence‐based psychotherapies for PTSD and other VA treatment

“…Participants’ experiences in qualitative interviews were consistent with their scores on self‐report measures associated with expressions of moral injury (EMIS). Participants reported heightened expressions of moral injury suggesting clinically significant experiences of moral injury (Currier et al, ; ) following completion of an EBP for PTSD (Table ). While the results should not be over‐generalized, the results from this sample of Veterans suggest that VA treatment in general and EBPs for PTSD more specifically may not sufficiently target moral injury‐related suffering in warzone Veterans.…”

“…Expressions of Moral Injury Scale (EMIS; Currier et al, ). The EMIS is a 17‐item self‐report scale used to measure expressions of moral injury in the domains of emotional well‐being, relationships and quality of life.…”

“…The consequences of exposure to MIEs have been found to be both related to and distinct from PTSD. One way of measuring the potential consequences of MIEs is through the Expressions of Moral Injury Scale (EMIS; Currier et al, ). On the EMIS, the consequences of exposure to MIEs are evaluated through asking participants questions about how their military service has impacted their emotional wellbeing, relationships, and quality of life.…”

Counseling Military Populations: A Content Analysis of Counseling Journals From 1998 to 2018

“…Psychology researchers are also investigating the clinical concerns of military populations. Currier et al (2015Currier et al ( , 2018 conducted several studies on the psychological impact of combat. These research teams have concentrated efforts to define and measure moral injury as an invisible wound of war.…”