Moral Injury: A Scoping Study of an Emerging Construct and Its Implications for Social Work

Background & Purpose

Moral injury refers to the lasting psychological impact of “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” (Litz et al., 2009, p. 700). The concept of moral injury was first identified by mental health practitioners providing services to military veterans who realized that many of the veterans were suffering from a type of psychological, and in some cases, existential distress that was not being captured by the DSM diagnosis of PTSD (Shay, 2014) nor alleviated by traditional PTSD interventions. In this paper, we present the results of a “scoping study” review of the existing moral injury literature, in which we examine the current scope and breadth of the research, assess the applicability of moral injury to various contexts, discuss its relevance to social work research and practice, AND identify areas for needed further study.

Methods:

Moral injury is a relatively new construct, thus we chose a scoping study methodology, which is particularly useful when considering a topic that has not yet been extensively studied, or is of a complex or heterogeneous nature (Arksey & O’Malley, 2005).  Although fairly common in medical research, scoping studies have not been utilized frequently in the social work.  In this presentation, we will discuss the scoping study methodology we used (Arksey & O’Malley, 2005; Daudt, van Mossel, & Scott, 2013; Levac, D., Colquhoun, J.H., O’Brien, K.K., 2010), including literature search and sampling procedures, charting of data, and analysis. 

Results:

We identified 59 studies published in peer-reviewed journals or as dissertations, 27 of which were empirical.  Although the vast majority (50) of these studies focused on moral injury among military veterans, findings from the review suggest that morally injurious events occur in a number of high-stakes contexts and among members of diverse groups, including those with substance abuse disorders, refugees, and educators. Intervention research suggests that self-forgiveness and meaning making may promote recovery from moral injury. More empirical research is needed to examine: (a) the extent to which the experience of moral injury varies depending on one’s role (victim, perpetrator, or observer), (b) the emotional experiences of moral injury as distinct from trauma, (c) the extent and experience of moral injury in social workers and social work clients, and (d) risk and protective factors for moral injury useful to the design of interventions.

 

Conclusions & Implications:  

The concept of moral injury is critical to social work educators, researchers and practitioners.  In recent years, social workers have been called to increase research and practice in the military setting, and an ability to identify and treat moral injury is of growing importance.  Secondly, a small number of studies have begun to consider the applicability of moral injury to other morally high-stakes contexts, many of which involve social work practice.  The impact of moral injury may play a significant role in increasing the vulnerability and mental health needs of some of the profession’s highest need clients as well as its practitioners.