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J Trauma Stress. 2019 Jun;32(3):350-362. doi: 10.1002/jts.22362. Epub 2019 Jan 28.

Moral Injury: An Integrative Review.

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Mental Health Service, San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA.
Department of Psychiatry, University of California-San Francisco, San Francisco, CA, USA.
Department of Social and Behavioral Sciences, University of California-San Francisco, San Francisco, CA, USA.
Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, MA, USA.
Departments of Psychiatry and Psychology, Boston University, Boston, MA, USA.
National Center for Veterans Studies, The University of Utah, Salt Lake City, UT, USA.
Department of Psychology, The University of Utah, Salt Lake City, UT, USA.
Department of Psychology, Palo Alto University, Palo Alto, CA, USA.


in English, Chinese, Spanish

Individuals who are exposed to traumatic events that violate their moral values may experience severe distress and functional impairments known as "moral injuries." Over the last decade, moral injury has captured the attention of mental health care providers, spiritual and faith communities, media outlets, and the general public. Research about moral injury, especially among military personnel and veterans, has also proliferated. For this article, we reviewed scientific research about moral injury. We identified 116 relevant epidemiological and clinical studies. Epidemiological studies described a wide range of biological, psychological/behavioral, social, and religious/spiritual sequelae associated with exposure to potentially morally injurious events. Although a dearth of empirical clinical literature exists, some authors debated how moral injury might and might not respond to evidence-based treatments for posttraumatic stress disorder (PTSD) whereas others identified new treatment models to directly address moral repair. Limitations of the literature included variable definitions of potentially morally injurious events, the absence of a consensus definition and gold-standard measure of moral injury as an outcome, scant study of moral injury outside of military-related contexts, and clinical investigations limited by small sample sizes and unclear mechanisms of therapeutic effect. We conclude our review by summarizing lessons from the literature and offering recommendations for future research.


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