Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium — TEI-tagged view

Brett T. LitzpersName, Rachel A. PlouffepersName, Anthony NazarovpersName, Dominic MurphypersName, Andrea PhelpspersName, Alanna CoadypersName, Stephanie A. HoulepersName, Lisa DellpersName, Sheila FrankfurtpersName, Gadi ZerachpersName, Yossi Levi-BelzpersName (2022date). “Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium.” Frontiers in Psychiatrytitle·j.

Object of study — the syndrome of moral injuryterm·dom in service members and Veteransterm·key, and its measurement

Research question — what the syndrome of moral injuryterm·dom consists of, and whether a scale built from lived experience measures it reliably and validly

Contribution — operational definitions of the domainsterm·mth of impact of PMIEsterm·dom and the 14-item Moral Injury Outcome Scaleterm·mth

Full text — tagged

Defining and Assessing the Syndrome of Moral Injuryterm·dom: Initial Findings of the Moral Injury Outcome Scaleterm·mth Consortium Abstract Potentially morally injurious eventsterm·dom (PMIEsterm·dom) entail acts of commission (e.g., cruelty, proscribed or prescribed violence) or omission (e.g., high stakes failure to protect others) and bearing witness (e.g., to grave inhumanity, to the gruesome aftermath of violence), or being the victim of others' acts of commission (e.g., high stakes trust violations) or omission (e.g., being the victim of grave individual or systemic failures to protect) that transgress deeply held beliefs and expectations about right and wrong. Although there is a proliferation of interest in moral injuryterm·dom (the outcome associated with exposure to PMIEsterm·dom), there has been no operational definition of the putative syndrome and no standard assessment scheme or measure, which has hampered research and care in this area. We describe an international effort to define the syndrome of moral injuryterm·dom and develop and validate the Moral Injury Outcome Scaleterm·mth (MIOSterm·mth) in three stages. To ensure content validityterm·mth, in Stage I, we conducted interviews with service members, Veteransterm·key, and clinicians/Chaplains in each country, inquiring about the lasting impact of PMIEsterm·dom. Qualitative analysis yielded six operational definitions of domainsterm·mth of impact of PMIEsterm·dom and components within domainsterm·mth that establish the parameters of the moral injuryterm·dom syndrome. From the domainterm·mth definitions, we derived an initial pool of scale items. Stage II entailed scale refinement using factor analytic methods, cross-national invariance testing, and internal consistency reliability analyses of an initial 34-item MIOSterm·mth. A 14-item MIOSterm·mth was invariant and reliable across countries and had two factors: Shame-Relatedterm·dom (SR) and Trust-Violation-Relatedterm·dom (TVR) Outcomes. In Stage III, MIOSterm·mth total and subscale scores had strong convergent validity, and PMIE-endorsers had substantially higher MIOSterm·mth scores vs. non-endorsers. We discuss and contextualize the results and describe research that is needed to substantiate these inaugural findings to further explore the validity of the MIOSterm·mth and moral injuryterm·dom, in particular to examine discriminant and incremental validity.

Keywords: moral injuryterm·dom syndrome, moral injury outcome scaleterm·mth, multinational, psychometric evaluation, moral injury outcome scaleterm·mth consortium Introduction The idea that people can be lastingly psychologically and socially affected by their own or others' transgressive behavior is as old as humanity. It is only recently that these age-old concepts have been considered as clinically relevant social, biological, and psychological problems. The term that is used to describe the outcome of these transgressive harms is moral injuryterm·dom (MIterm·dom). As is the case with the distinction between stressors and stress, transgressive experiences are best construed as potentially morally injurious eventsterm·dom (PMIEsterm·dom), rather than inherently and enduringly impairing. PMIEsterm·dom entail acts of commission or omission by oneself (e.g., cruelty, failure to prevent serious injury), or bearing witness to, learning about, or being the direct victim of acts of commission or omission of others (e.g., high stakes betrayal by an individual or institution, witnessing cruel behavior), that transgress deeply held moral beliefs and expectations ( 1 – 4 ). MIterm·dom has been most studied in Veteransterm·key for good reason; a sizeable minority (24%−40%) of deployed service members (SMs) and combat Veteransterm·key report exposure to PMIEsterm·dom during their military service ( 2 – 4 ).

LitzpersName et al. ( 1 ) posited that PMIEsterm·dom are potentially harmful because they can undermine foundational beliefs about the goodness and trustworthiness of oneself or others, causing functionally impairing psycho-social-spiritual problems. Currier et al. ( 5 ), Farnsworth et al. ( 6 ), Jinkerson ( 7 ), and LitzpersName et al. ( 1 ) posited that there are areas of overlap and distinction between MIterm·dom and other mental and behavioral health outcomes. We hypothesized that the outcomes associated with exposure to PMIEsterm·dom closely resemble PTSDterm·key, as is the case with the potential aftermath of any high magnitude life stressor. When PMIEsterm·dom are impairing (a person putatively is experiencing MIterm·dom), memories of the experiences can be haunting (intrusively reexperienced) and individuals are motivated to avoid reminders of the event(s) because they cue painful functionally impairing moral emotions, namely shameterm·dom, guilt, angerterm·dom, and disgust ( 1 ). Additional overlapping PTSDterm·key symptoms entail restricted range of non-moral emotions, disinterest in pleasurable activities, and detachment from others, which are also symptoms of depression. MIterm·dom is posited to have two non-exclusive forms, namely, internalizing outcomes associated with personal transgressive acts and externalizing outcomes associated with being the victim of other's transgressions ( 8 ). The distinctive features of MIterm·dom are posited to be unique enduring changes in self-schemas and beliefs about others that reflect over-accommodation of moral violation, culpability, or expectations of injustice, as well as estrangement, and risky (e.g., reckless) or self-destructive behaviors ( 1 ). Although a sizeable percentage of traumatic events endorsed by SMs and war Veteransterm·key with PTSDterm·key entail morally injurious events, MIterm·dom is uniquely associated with additional symptoms and problems among PTSDterm·key cases ( 3 ). However, a frequent false assumption is that for PMIEsterm·dom to substantively impact outcomes, these events are de facto Criterion-A traumas or take place within a life-threatening context. While PMIEsterm·dom can be classified as traumatic events (e.g., sexual assaults in the military), many do not involve life-threat and/or sexual assault (e.g., drone strikes, humiliation of a prisoner of war, high stakes trust violations). Finally, although MIterm·dom and PTSDterm·key overlap as described above, some apparently overlapping symptoms may differ functionally [e.g., vigilance about potential betrayal, detachment or angerterm·dom as a means to avoid shameterm·dom; ( 6 )].

Reports of PMIEsterm·dom have also been shown to be associated with suicidal ideation and behavior, angerterm·dom/aggression, depression/hopelessness, guilt/self-blame, alcohol misuse ( 3 , 4 , 9 , 10 ), impairments in occupational and social/relationship functioning ( 11 ), and spiritual or existential conflicts or deficits ( 12 ). However, these studies have been hampered by typically small samples of convenience, and the findings are generally of very small magnitude and have questionable replicability. Generally, research about MIterm·dom and efforts to treat the putative clinical aftermath of exposure to PMIEsterm·dom are hindered by a lack of consensus about the problems uniquely and reliably associated with exposure to PMIEsterm·dom (the putative syndrome of MIterm·dom) and the lack of a gold standard measure of MIterm·dom as an outcome. The lack of a gold standard measure is particularly problematic with respect to identifying clinical cases of MIterm·dom, planning treatment for those cases, tracking change in MIterm·dom symptoms over the course of treatment, and evaluating effectiveness. Although treatments have been developed to purportedly target MIterm·dom, this work has been somewhat cart before horse. Without a gold standard measure of MIterm·dom as an outcome, it is impossible to demonstrate efficacy. Finally, advancements in the field have been particularly hampered by the absence of qualitative evaluations of the lived experiences of individuals exposed to moral harms. Instead, most studies that have generated ideas about the parameters of the MIterm·dom construct have interviewed putative experts and clinicians or administered existing mental and behavioral health questionnaires. Given the lack of consensus about, and rhetorical fuzziness associated with MIterm·dom ( 8 , 13 ), expert opinion is widely varying and has uncertain validity. Consequently, the lack of qualitative data on how people suffer after exposure to transgressive acts represents a particularly significant knowledge gap in the field.

There are two extant measures of MIterm·dom as an outcome, namely the Moral Injuryterm·dom Symptom Scale—Military Version [MISS-M ( 14 )] and the Expressions of Moral Injuryterm·dom Scale—Military Version [EMIS-M ( 5 )]. The MISS-M was created by compiling items from existing outcome scales that the authors judged to be face valid. Additional items that putatively assessed domainsterm·mth not assessed in existing scales were derived by the authors or from other studies. The initial scale was subjected to exploratory and confirmatory factor analyses in a sample of Veteransterm·key and active-duty SMs. The authors failed to follow state-of-the-art steps in test construction and validation ( 15 ) and failed to establish content validityterm·mth ( 16 ), to ensure the meaningfulness of scale content.

The items for the EMIS-M ( 5 ) were developed in a four-stage process that included: (a) a literature review and consultation with three putative subject matter experts to identify MIterm·dom; (b) an unspecified review of existing measures of relevant constructs; (c) creating an initial pool of items and soliciting feedback from clinicians and researchers; and (d) refining the item pool in consultation with putative subject matter experts. The initial scale was subjected to exploratory factor analysis in a college student Veteranterm·key sample. The EMIS-M correlated positively with PTSDterm·key and depression symptoms and was inversely associated with social support, hope, and gratitude in the student Veteranterm·key sample. The authors generated content from existing scales and by appealing to putative experts. We argue that this constrains content validityterm·mth, which should entail consulting the target population to ensure the meaningfulness and comprehensiveness of scale content ( 16 ). Another problem with the EMIS-M is that the scale items ask respondents to rate symptoms relative to “the military or the military experience,” failing to index symptoms to a specific worst and currently distressing PMIEterm·dom, which also limits the scale's applicability outside the military context. Without event linkage, the EMIS-M is questionably helpful to clinicians who may wish to target the meaning and implication of a specific event and to track change in MIterm·dom yoked to the most currently distressing and targeted event. An additional problem with the EMIS-M is that respondents are not asked to rate symptoms within a specific time period. This means that the scale might be assessing traits rather than states and would have difficulty tracking clinical change. Finally, the EMIS-M does not measure the functional impact of the symptoms endorsed, which LitzpersName and Kerig ( 8 ) argued is a way of distinguishing moral frustration and distress (resulting from moral challenges and stressors, respectively) from MIterm·dom (based on exposure to PMIEsterm·dom).

We describe an international effort to develop and validate a questionnaire measure of MIterm·dom as an outcome, the Moral Injury Outcome Scaleterm·mth (MIOSterm·mth). This research was conducted by a consortium comprised of researchers and clinicians working with active-duty military SMs and Veteransterm·key in the US, the United Kingdom (UK), Israel, Australia, and Canada. We paid considerable attention to ensuring a high degree of content validityterm·mth for the MIOSterm·mth. We conducted qualitative interviews of SMs, Veteransterm·key, clinicians (psychologists, social workers, mental health nurses), and Chaplains from each participating country. We then used the results, as well as theory, to generate operational definitions of the cross-country domainsterm·mth of impact of PMIEsterm·dom (and components within domainsterm·mth) that do not overlap with PTSDterm·key or depression, with the dual aim of defining the syndrome of MIterm·dom and to generate scale items ( 17 ). The construct and measure development process were divided into three stages, following the methods described by Haynes et al. ( 16 ) and Vogt et al. ( 18 ). Stage I included content generation and creation of the initial measure. Stage II entailed scale refinement and invariance testing (e.g., item reduction and revisions of the structure and format of scale). Stage III entailed an additional test of construct validity of the final iteration of the MIOSterm·mth via an examination of convergent validity. (A study of discriminant and incremental validity is in the planning stages).

Stage I: Item Generation and Initial Scale Construction We used theory and consensus among consortium members to generate an initial set of domainsterm·mth of impact from exposure to PMIEsterm·dom. These hypothesized domainsterm·mth of impact were used to generate prompt questions in a semi-structured interview, which was used to substantiate these domainsterm·mth and discover new domainsterm·mth and specific components (elements) within all domainsterm·mth. The aim was to use thematic analysis to capture the phenomenology of participants' lived experience ( 19 ), to generate operational definitions of an invariant, best-fitting set of domainsterm·mth of impact and components within domainsterm·mth, from which to generate content-valid items for the MIOSterm·mth. The domainsterm·mth and components within domainsterm·mth were conceptualized as higher and lower order parts, respectively, of the nomological network that defines the MIterm·dom construct. A large pool of items was generated from each component definition within each domainterm·mth, and these were pared down by categorizing whether items well-fit each domainterm·mth. Then, a card sort task was used to generate an initial item set for the MIOSterm·mth (some items were re-worded and additional items were generated to fill gaps).

Methods Procedure and Results We conducted qualitative semi-structured interviews of SMs, Veteransterm·key, and clinicians (and clergy) with experience treating SMs and Veteransterm·key across consortium countries. Prior to SM and Veteranterm·key interviews, we asked respondents a series of demographic and military history questions, and we asked them to identify and describe the worst and most currently distressing military experience that went against their beliefs about right and wrong.

We generated a semi-structured interview in which we asked SMs and Veteransterm·key to describe the ways that their life changed as a result of the worst and most currently distressing PMIEterm·dom (and we asked clinicians what they observed). The initial prompt questions asked SMs and Veteransterm·key to reflect on an initial hypothesized set of domainsterm·mth of impact, namely: (1) the presence of moral emotions (e.g., how do you feel now as you are thinking about this event?); (2) alterations in self-perception (e.g., how has this event changed the way you see or feel about yourself; the way you care for yourself; your plans for the future?); (3) social impacts (e.g., how has this event changed your relationships with family, friends, romantic partners, and co-workers; what about your trust in other people; dealing with authority figures; how close or distant you feel toward others; how you care for others?); and (4) beliefs about life's meaning and purpose (e.g., how has this event affected the way you make sense of life and your spirituality or religious beliefs [faith], your understanding of right and wrong, the principles that guide your life?). The interview for clinicians/clergy framed these questions as observations across patients.

Seven SMs, 65 Veteransterm·key, 64 clinicians, and 12 Chaplains were interviewed in total (see Supplementary Material for the consortium site contributions). Interviews were audio-taped and transcribed. All efforts were approved by the internal review (ethics) board of the respective sites. The initial qualitative analysis was conducted by two teams, one in the US and one in Canada. In Boston, two trained and well-versed research assistants, and in Ottawa, three clinicians, repeatedly read the transcripts, generated initial codes, and searched for and reviewed themes ( 20 ). This process was carried out using NVivo 12 qualitative coding software. The meta-frame for this process was the assumption that PMIEsterm·dom can adversely affect behavior and ways of thinking, feeling, and relating, and that MIterm·dom subsumes two separable sub-constructs, namely, the unique aftermath of PMIEsterm·dom that entail personal actions (or omissions), and the unique aftermath of PMIEsterm·dom that entail bearing witness to or being directly impacted by the transgressions of others. In addition, raters understood that in theory, self-transgressions were associated with shameterm·dom, a self-conscious and self-condemning emotion, and others' norm violations produce angerterm·dom, an other-condemning emotion ( 1 ). The two teams met in person to discuss their findings and to generate consensus definitions of themes. We relied on theory and data to identify themes pertinent to generating operational definitions of domainsterm·mth of impact.

The US team coded eight interviews for the initial codebook, one active-duty US SM, four Veteransterm·key (one from Australia, two from the UK, and two from the US), and three clinicians (one from Australia, one from the UK, and one from the US). The codebook was then tested at each of the sites on at least four of their local interviews. A priori, consortium members decided that the MIOSterm·mth should be designed to maximize incremental validity relative to related constructs, such as PTSDterm·key and depression. Consequently, at first, coders coded everything that was present in the data and then removed all codes that entailed prototypic DSM-5 diagnostic criteria for PTSDterm·key and depression (e.g., intrusive experiences, anhedonia). They also removed codes that described PMIEsterm·dom and codes suggesting positive outcomes of exposure to PMIEsterm·dom. An initial codebook was sent to consortium sites so they could code their site-specific data. Consortium members met monthly via conference calls to identify gaps and inconsistencies and to further refine the codebook. The final codebook consisted of “themes,” subsequently renamed domainsterm·mth, and “codes,” renamed as components. The domainterm·mth definitions are presented in Table 1 (components within domainsterm·mth are in Supplementary Material ).

Domainsterm·mth of impact and their operational definitions.

Next, separately, each consortium site member generated a large initial pool of scale items that tapped content consistent with the definitions of each component within domainsterm·mth. The non-overlapping items were culled and edited for clarity and simplicity of language, resulting in a set of approximately 300 items. The individuals in each site that had content knowledge or clinical experience pertaining to MIterm·dom then rated each item from the 300-item pool with respect to whether the item was a “Core” or “Not Core” fit with the operational definition of the respective domainsterm·mth. The 49 items retained were primarily “I statements” to assess personal constructions about behavioral repertoires, ways of thinking (beliefs), ways of feeling, and ways of relating to others that were altered by exposure to PMIEsterm·dom.

We then created an online card sorting task that included the operational definitions of each domainterm·mth at the top of the page. A separate group of 19 support staff and research assistants across the consortium, unfamiliar with the MIOSterm·mth project or MIterm·dom, were asked to move each item into virtual domainterm·mth bins. Twenty-seven items in which at least 50% of the raters agreed were retained (six of these were reworded to enhance clarity). The total interrater agreement for these 27 items was moderate [Kappa = 0.45, 95% CI, (0.17, 0.72)]. To ensure that the MIOSterm·mth covered content that consortium members deemed important, upon reflection, an additional seven items were created (e.g., we determined that the existing content did not capture the loss of previously valued aspects of the self or constructions of others; an example item was “I have lost pride in myself”). The original list of items retained from the “core” “not core” process, the 27 items retained from the card sort (as well as the rewording), and the additional seven items are presented in Supplementary Table 1 .

Finally, we generated a working instructional set and response framework for the initial 34-item MIOSterm·mth to be tested in Stage II, incorporating feedback about item content and the form of the MIOSterm·mth from subject matter and questionnaire design experts, respectively. The first page of the MIOSterm·mth establishes whether a respondent experienced a PMIEterm·dom, and if so, respondents are asked to categorize their worst and most currently distressing PMIEterm·dom (respondents are asked to select “Yes” or “No” in response to the following questions: Did the event involve something you did or failed to do?; Did the event involve observing someone else acting [or failing to act]?; Did the event involve being directly impacted by someone else [or people] acting [or failing to act]?). We then asked respondents to report the year that the event happened, and we asked a question to determine if the event meets the Criterion-A definition of a traumatic event; we used the primary care PTSDterm·key screener questions ( 21 ) to assess PTSDterm·key symptoms related to the PMIEterm·dom. We did this because of research that has shown that Criterion-A events can entail moral injuries ( 3 ) and to explore possible PTSDterm·key as a comorbid problem among individuals exposed to PMIEsterm·dom. The research version of the MIOSterm·mth used in Stage II and III allowed those without a PMIEterm·dom to answer the PTSDterm·key screener questions and to fill out the MIOSterm·mth with a most currently distressing stressor in mind to test the linkage between PMIEterm·dom exposure and MIOSterm·mth scores.

On the second page of the MIOSterm·mth, we asked respondents to write out the worst and most currently distressing PMIEterm·dom if they were comfortable doing so. This was followed by the preliminary 34 MIOSterm·mth items, listed in random order. The instruction was: “Keeping this worst event in mind, please read each of these statements and circle one of the numbers to the right to indicate how much you would agree with the statement in the past month.” The response options were Likert-type, according to degree of agreement. We asked respondents to judge the global impact of the MIOSterm·mth items on a Likert-type scale between 0 ( not at all ) to 6 ( extremely ) in terms of how much these experiences made it hard for respondents to take care of themselves (e.g., do pleasurable things, exercise, eat properly), and whether they were effective in their job, in school, seeking employment, or getting along with other people.

Stage II: Examining Factor Structure and Item Trimming The 34-item version of the MIOSterm·mth was administered to Veteransterm·key and/or active-duty SMs in each participating country (Canada had two sites). All participants were different from the participants in Stage I. Analyses entailed an examination of the factor structure of the MIOSterm·mth, using exploratory factor analyses (EFA). The Canada sample was used as the reference group because these were the first Stage II data collected. This was followed by confirmatory factor analysis (CFA) derived from the EFA model, also with the Canada sample, and cross-national multigroup invariance testing of the model. Finally, we report the interitem and item-total correlations, and internal consistency reliability of the trimmed scale.

Methods Participants Canada (non-clinical sample). Canadian Armed Forces (CAF) Veteransterm·key were recruited to participate in a 30-min online surveyterm·mth comprising the MIOSterm·mth and a series of additional psychological, social, and physical well-being measures as part of a larger study exploring Veteranterm·key well-being. They were recruited via word of mouth, email distribution through professional and Veteranterm·key group networks, participant recruitment websites, and social media. Research Electronic Data Capture (REDCap) was used to collect data. This research was approved by the Western University Health Sciences Research Ethics Board. Participants included 533 Veteransterm·key (71% men, mean age = 51.87 years [SD = 9.77]). Three hundred and sixty-six participants (68.7%) endorsed a PMIEterm·dom. Of those who endorsed a PMIEterm·dom, 49.7% endorsed a MI-Self, 71.0% endorsed observing a MI-Other based on observation of a transgression, and 82.5% were directly impacted from an MI-Other. The most common single type was direct impact from MI-Other (10.4%).

United States (non-clinical sample). Three hundred sixty-three Veteransterm·key participated in an online surveyterm·mth study conducted by Qualtrics comprising the 34-item MIOSterm·mth. Of the 360 Veteransterm·key who participated in the study, 73.6% were men; ages ranged from 20 to 79 ( M range = 50–59). Seventy-eight percent endorsed a PMIEterm·dom [39% endorsed each type of PMIEterm·dom (MI-self, MI-Other, and MI-O being directly impacted by another's transgression)]. Of those that only endorsed a single type, the most common was MI-self (11%). The research was approved by the IRB at the VA Boston Healthcare System.

Canada (Ottawa; clinical sample). Two hundred thirty-nine individuals with a treatment history of operational stress injuries participated in an online surveyterm·mth study using the 34-item MIOSterm·mth. Of the 239 Veteransterm·key who participated in the study, 74.8% were men; the age range was 20–79 years ( M range = 50–59). 89.9% of participants endorsed a PMIEterm·dom: 51% endorsed an MI-Self, 74.6% endorsed observing an MI-Other, and 79.6% endorsed being directly impacted by a MI-Other. The most common single type was direct impact from MI-Other (9%). The research was approved by the Royal Ottawa Research Ethics Board.

United Kingdom (non-clinical sample). Two hundred sixty-four Veteransterm·key from the United Kingdom (UK) participated in an online surveyterm·mth study of the 34-item MIOSterm·mth. Of the 264 Veteransterm·key who completed the MIOSterm·mth, 67% were men; the mean age range was 51–60 years. All participants reported a PMIEterm·dom (65.9% MI-Self; 64.4% observing a MI-Other, and 70.1% directly impacted by a MI-Other). MI-S was the most common single type (11.7%). The research was approved by the Combat Stress Research Committee.

Australia (non clinical sample). One hundred eighteen Defense members and Veteransterm·key participated in a surveyterm·mth study using the 34-item MIOSterm·mth. Mean age range was 40–49 years. The MIOSterm·mth was administered to participants either online or in person; 65.9% of participants identified as male. Of those who endorsed a PMIEterm·dom, 55% endorsed a MI-Self, 79% endorsed observing a MI-Other, and 87% endorsed being directly impacted by an MI-Other. The most common single PMIEterm·dom was the latter (12%). The research was approved by the Departments of Defense and Veteransterm·key' Affairs Human Research Ethics Committee.

Data Analytic Strategy To investigate the dimensionality of the preliminary 34-item MIOSterm·mth, we conducted an EFA with the Canadian sample using SPSS Version 26.0 ( 22 )?. All participants completed at least 80% of the MIOSterm·mth; we used pairwise deletion to handle missing data. Adequacy of data for factor analysis was measured using the Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy, with values above 0.60 reflecting suitability for analysis ( 23 ), and Bartlett's test of sphericity ( 24 ), with statistically significant values indicating that item correlations are significantly different from zero. We used principal axis factoring (PAF) with direct oblimin rotation. Items were retained based on theory, consideration for item redundancy, and a cut-off value of 0.30 ( 25 ). Parallel analysis ( 26 ), very simple structure ( 27 ), Scree plots, and theory were considered to determine the number of factors to extract.

Using the Canada (Ottawa), US, UK, and Australian samples we conducted CFAs, with MPlus Version 8.0 ( 28 ). Sample sizes of at least 200 are recommended for CFA ( 29 ). The maximum likelihood estimator was used, and missing data were estimated using the full-information maximum likelihood. We used root mean square error of approximation (RMSEA), comparative fit index (CFI), and the Tucker-Lewis index (TLI) to evaluate model fit. Values of 0.06 reflected good fit, 0.07–0.08 acceptable fit, 0.08–0.10 marginal fit, and >0.10 poor fit; also, CFI and TLI values of >0.95 reflected excellent model fit and 0.90–0.95 indexed acceptable fit ( 30 ).

To evaluate cross-national invariance of MIOSterm·mth scores, a series of multi-group confirmatory factor analytic (MGCFA) models were tested; the US and UK samples were each compared to the Canadian (Ottawa) sample. Three levels of invariance were tested: configural (i.e., number of factors is equivalent across groups), metric invariance (i.e., factor loadings are equivalent across groups), and scalar invariance (i.e., intercepts are equivalent across groups). If scalar invariance is satisfied, latent means can be reliably compared across groups; otherwise, intercept constraints can be freed sequentially to examine partial scalar invariance ( 31 ). Nested MGCFA models were compared using χ 2 , CFI, and RMSEA difference tests. CFI difference values less than or equal to 0.01, RMSEA difference values less than or equal to 0.01, and non-significant χ 2 difference tests indicate that invariance is satisfied ( 31 , 32 ).

Due to the small sample size ( n = 118), we evaluated the invariance of the Australian sample compared to the Canadian sample using multiple indicators, multiple causes [MIMIC; ( 33 , 34 )] modeling, which does not require large sample sizes ( 35 ). Using MIMIC modeling, we tested for invariance across item intercepts and factor means. The covariate, country, was regressed onto the MIOSterm·mth factors. If these coefficients are non-significant, then cross-national invariance of the factors is satisfied. In addition, we regressed country onto each item and fixed the direct effects to zero; following this, we examined the modification indices to determine whether any of the item intercepts were noninvariant ( 35 ). Where no modification indices emerged, we concluded that cross-national invariance of the intercepts was satisfied.

Results Exploratory Factor Analysis We determined that the Canadian sample was suitable for an EFA because we found a KMO index of 0.96 and Bartlett's test of sphericity was significant, χ ( 561 ) 2 = 12,789.11, p < 0.001. When all initial 34 items were included, initial Eigenvalues and parallel analysis suggested that five factors should be retained (see Supplementary Figure 1 ). However, only one item loaded onto Factor 5, three items loaded onto Factor 4, and four items loaded onto Factor 3 without cross-loadings. In addition, the Scree plot and very simple structure indicated that two factors should be retained. A two-factor solution was consistent with theory and how we approached content development, namely that MIOSterm·mth items would describe the outcomes unique to a MI-Self experience (we called this Factor 1, Shame-Relatedterm·dom; SR ), and uniquely applicable to MI-Other experiences (we called this Factor 2, Trust-Violation-Relatedterm·dom; TVR) . An EFA using the 34 items found that Factors 1 and 2 accounted for 44.64% and 6.02% of the variance across items, respectively. The two factors correlated at 0.47. The factor loadings for the Canadian Stage II study for the preliminary 34-item scale are presented in Supplementary Material .

Next, we sought to reduce the scale to a parsimonious number of items while ensuring that content validityterm·mth was maintained across the two factors. We sequentially removed items based on a combination of the following empirical and theoretical reasons: (1) factor loadings below 0.30; (2) cross-loadings exceeding 0.30; (3) maintaining coverage of all domainsterm·mth of impact; and (4) the redundancy of items. First, three items were removed due to low communalities. Next, five items were removed due to substantial content overlap (e.g., “I blame myself” was kept, “I feel guilty about what happened” was dropped). Next, three items were removed due to cross-loadings. Finally, nine items with some content overlap were removed from Factor 1 to maintain an approximately equal number of items across the factors (the items that comprise the SR and TVR subscales are presented in Table 2 ).

Pattern matrix factor loadings for 14-item moral injury outcome scaleterm·mth.

We then conducted an EFA using the final 14-item MIOSterm·mth. The KMO index (0.93) and Bartlett's test of sphericity [ χ ( 91 ) 2 = 3,302.71, p < 0.001] indicated that the data were suitable for EFA. Factor 1 accounted for 42.15% of variance among items, while Factor 2 accounted for 5.75% of variance. The two factors were correlated at 0.74, indicating that they represent unique but associated elements of MIterm·dom (with 55% shared variance). Item loadings were strong (see Table 2 ), ranging from 0.30 (“I no longer believe there is a higher power”) to 0.91 (“I am not the good person I thought I was”). Although the loading for “I no longer believe there is a higher power” was weaker than the remaining loadings, it was important to include this item to preserve the content domainterm·mth reflecting beliefs about life meaning and purpose.

Descriptive Results Table 3 shows the means, standard deviations, and Cronbach's alphas for the 14-item MIOSterm·mth for each sample. Internal consistency values were acceptable, ranging from 0.85 (Ottawa) to 0.90 (US and Canada) for the 14-item MIOSterm·mth. The Stage II bivariate correlations between SR and TVR subscale scores were 0.66, 0.51, 0.68, 0.67, and 0.50 in the Canada, Ottawa, US, UK, and Australian study groups, respectively.

Descriptive statistics for 14-item moral injury outcome scaleterm·mth.

Item-level descriptive statistics, inter-item, and item-total correlations for the 14-item MIOSterm·mth for the Canadian sample are shown in Table 4 (other Stage II consortia results are presented in Supplementary Material ). Although there is no consensus regarding optimal inter-item correlation range, Clark and Watson ( 15 ) suggested that the average item-total correlation should range between 0.15 to 0.50. The average inter-item correlation for the MIOSterm·mth was 0.40, which provides evidence that the items represent the same underlying construct, but they are not redundant. Additionally, all item-total correlations reached a recommended cutoff of 0.30 ( 15 , 36 ), but were not so high as to suggest that the measure lacks breadth of content [( 37 ); uncorrected r range = 0.42–78, corrected r range = 0.30–73].

Moral injury outcome scaleterm·mth descriptive statistics and inter-item/item-total correlations—Canada.

Confirmatory Factor Analyses Using the Ottawa sample, the 14-item two-factor model fit the data well, χ ( 76 ) 2 = 154.56, p < 0.001, CFI = 0.923, TLI = 0.907, RMSEA = 0.066 (90% CI = 0.051, 0.081). Factor loadings were strong, ranging from 0.30 (“I am disgusted by what happened”) to 0.79 (“I feel like I don't deserve a good life”), and the factors were significantly correlated at 0.65. In the US sample, the two-factor model also fit the data well: χ ( 76 ) 2 = 179.01, p < 0.001, CFI = 0.954, TLI = 0.944, RMSEA = 0.061 (90% CI = 0.050, 0.073; see Supplementary Figure ). All items loaded significantly onto their respective factors, ranging from 0.32 (“I no longer believe there is a higher power”) to 0.81 (“I feel like I don't deserve a good life”), and the factors were significantly correlated at 0.77. Finally, the UK model fit the data well: χ ( 76 ) 2 = 171.14, CFI = 0.928, TLI = 0.913, RMSEA = 0.069 (90% CI = 0.055, 0.083). Loadings were strong for the UK sample, ranging from 0.46 (“People don't deserve second chances”) to 0.77 (“I am not the good person I thought I was”), and the factors were significantly correlated at 0.78. Although the correlations were high, they do not exceed the cutoff values of 0.80 to 0.85 and are therefore not considered redundant ( 35 ).

Cross-National Invariance The US—Ottawa configural model fit the data well, χ ( 152 ) 2 = 331.72, p < 0.001, CFI = 0.944, TLI = 0.933, RMSEA = 0.063 (90% CI = 0.053–0.072) indicating that the number of factors was consistent across countries (see Table 5 ). Factor loadings were also equivalent between the US and Ottawa samples [Chi-square, CFI, and RMSEA difference tests demonstrated no significant differences in fit between the metric and configural models, Δ χ ( 12 ) 2 = 12.39, p > 0.05, ΔCFI = 0.000, ΔRMSEA = 0.003]. Next, the RMSEA difference test revealed that the scalar invariance model was not significantly different from the metric model, ΔRMSEA = 0.004. However, both the chi-square and CFI difference tests surpassed the cut-off values, Δ χ ( 12 ) 2 = 49.20, p < 0.01, ΔCFI = 0.012. When we freed the intercept for the item “I feel like I don't deserve a good life,” we achieved partial scalar invariance according to CFI and RMSEA difference tests, Δ χ ( 11 ) 2 = 34.14, p < 0.01, ΔCFI = 0.007, ΔRMSEA = 0.002. We compared latent means and found no significant differences between the US and Ottawa in SR Outcomes (Δ m = 0.13, p = 0.097), but Canada scored higher than the US on latent TVR Outcomes (Δ m = 0.20, p = 0.002).

Cross-national invariance fit indices.

The UK—Ottawa configural model also showed strong fit to the data, χ ( 152 ) 2 = 326.14, p < 0.001, CFI = 0.925, TLI = 0.910, RMSEA = 0.068 (90% CI = 0.057–0.078). According to the chi-square, CFI, and RMSEA difference tests, the metric model did not differ significantly from the configural model, Δ χ ( 12 ) 2 = 14.37, p > 0.05, ΔCFI = 0.001, ΔRMSEA = 0.003, indicating that factor loadings were equivalent across countries. Although the RMSEA difference test indicated that scalar invariance was satisfied, ΔRMSEA = 0.007, the chi-square and CFI difference tests revealed that scalar invariance was not met, Δ χ ( 12 ) 2 = 66.03, p < 0.01, ΔCFI = 0.023. After freeing the intercept for “People don't deserve second chances”, partial scalar invariance was satisfied, Δ χ ( 11 ) 2 = 14.04, p > 0.05, ΔCFI = 0.009, ΔRMSEA = 0.001. Therefore, mean differences were calculated, and UK scored significantly higher than Canada on latent SR Outcomes (Δ m = 0.59, p < 0.001), as well as latent TVR outcomes (Δ m = 0.16, p = 0.020).

MIMIC Model First, we regressed country (Australia and Canada) onto both MIOSterm·mth factors. This model fit the data well, χ ( 88 ) 2 = 184.15, p < 0.001, CFI = 0.940, TLI = 0.928, RMSEA = 0.055 (90% CI = 0.044–0.067). As expected, the covariate country did not have a significant effect on SR (β = 0.03, SE = 0.086, p = 0.688) or TVR outcomes (β = 0.008, SE = 0.079, p = 0.919). Next, we regressed country onto each item and fixed the direct effects to zero. Modification indices were <3.12, indicating cross-country fit ( 35 ).

Finalization of the MIOSterm·mth Based on feedback from clinicians and an evaluation of consortium members about the MIOSterm·mth scale, we finalized the formatting. The final research version of the MIOSterm·mth has two pages. The first page entails an assessment of exposure to three types of PMIEsterm·dom, defined as events that went against the person's moral code or values [doing something or failing to do something, observing someone else acting or failing to act, or being directly impacted by someone else (or people) acting or failing to act]. We retained the primary care PTSDterm·key screener items ( 21 ). The second page of the research version of the MIOSterm·mth assesses the final set of 14 items determined from Stage II analyses, all indexed to the PMIEterm·dom that is the worst and most currently distressing. The time frame for ratings is the last month. Scale scores are indexed by the sum of item scores. The final research version and the brief clinical versions of the MIOSterm·mth are presented in the Supplementary Material (the MIOSterm·mth is a public domainterm·mth scale), along with scoring instructions. A brief version of the MIOSterm·mth for clinical care and epidemiological studies is also presented in the Supplementary Material .

At the end of the MIOSterm·mth, we decided to use the Brief Inventory of Psychosocial Functioning [B-IPF; ( 38 )] to assess the functional impact of the MIOSterm·mth symptoms endorsed across seven domainsterm·mth (romantic relationships, relationships with children, family relationships, friendships, work, training/education, and day to day activities). The B-IPF has high internal consistency and adequate test-retest reliability ( 38 ). The instructions embedded in the MIOSterm·mth are: “Please write in a number for each item below that represents how much these experiences have made it hard for you to function in each of the following areas (if not applicable, use N/A)” The MIOSterm·mth is designed to assess symptom burden (severity), but it is also designed to identify cases that have clinically significant functionally impairing symptoms. This will require future diagnostic utility studies, using signal detection analyses, with severe functional impairment as the criterion.

Stage III: Test-Retest Reliability and Convergent Validity Predictions We predicted that MIOSterm·mth total and subscale scores would be strongly associated with measures of constructs that have been hypothesized to be overlapping parts of the MIterm·dom syndrome or that are similar to the domainsterm·mth of impact generated in Stage I. These are: (1) depression . LitzpersName et al. ( 1 ) predicted that MIterm·dom would be associated with dysphoria, hopelessness, and self-esteem deficits; (2) PTSDterm·key . LitzpersName et al. ( 1 ) predicted that individuals suffering because of exposure to PMIEsterm·dom would experience intrusive recall and avoidance, as well as disinterest and detachment; and (3) functional impairments . Several domainsterm·mth of impact entail functional deficits and we have posited that the dividing line between moral distress and injury is chiefly the degree of functional impact related to the PMIEterm·dom.

We had two sets of predictions of variables that would distinguish the MIOSterm·mth SR and TVR subscales, namely: (1) that relative to MIOSterm·mth TVR subscale scores, SR subscale scores would be more strongly correlated with reports of the moral emotions of guilt/shameterm·dom and religious and spiritual beliefs and practices . The latter hypothesis is that personal transgressive acts are more likely to be morally injurious because they entail questions about right and wrong and good and evil ( 39 ); and (2) that relative to MIOSterm·mth SR subscale scores, TVR scores would be more highly correlated with reports of the moral emotion of angerterm·dom and anger-related problems . The assumption is that TVR MIterm·dom entails externalizing, relative to SR MIterm·dom. We also examined the association between the MIOSterm·mth and the EMIS-M ( 5 ).

Finally, to investigate the validity of the assumption that MIterm·dom is a PMIE-linked problem and the validity of the event-linkage aspect of the MIOSterm·mth (i.e., indexing symptoms to a putative worst and most currently distressing PMIEterm·dom), we ensured that 70 US participants (see below) who did not endorse a PMIEterm·dom would be allowed to participate in the surveyterm·mth (MIOSterm·mth ratings were instead indexed to a worst and most currently distressing life stressor). We predicted that individuals who did not endorse a PMIEterm·dom would have substantially lower MIOSterm·mth total and subscale scores, relative to participants who endorsed a PMIEterm·dom.

Methods Procedure We report studies conducted in the US, Australia, and Israel (all participants were different from the participants in Stage I and II and all samples were non-clinical). For the US study, the final 14-item MIOSterm·mth was administered along with the measures described below (and a demographic and military service characteristics form) in an online 30-min surveyterm·mth study of US Veteransterm·key conducted by Qualtrics. Qualtrics recruited participants via various web-based sources, including website intercept recruitment, member referrals, targeted email lists, gaming sites, customer loyalty web portals, permission-based networks, and social media. Qualtrics then administered the surveyterm·mth to a nationally representative sample of 420 US military Veteransterm·key ( n = 317) and active-duty SMs in the US military ( n = 103), who had been deployed to a post-9/11 conflict. Participants were also required to have experienced a PMIEterm·dom to complete the surveyterm·mth. However, Qualtrics was asked to accrue a subset of US participants ( n = 70) who had not experienced a PMIEterm·dom to conduct planned comparative analyses of MIOSterm·mth scores between those who had experienced a PMIEterm·dom vs. those who had not. For the Australia study, the measures were administered in an online surveyterm·mth of current and ex-serving members of the military aged 18 years or older who endorsed a PMIEterm·dom during military service. Participants were recruited through advertising in social media and through Defense, the national veteransterm·key counseling service and ex-service organizations. There were 91 participants (34 current serving and 57 ex-serving members). For the Israel study ( n = 111), the MIOSterm·mth was translated to Hebrew by a coauthor and then back-translated into English by another author, both native English and Hebrew speakers; each agreed that the original version and the back translation were similar, and no additional modifications were required. Measures were administered in an online surveyterm·mth of current and ex-serving Israeli members of the military. Recruitment entailed advertisements in combat Veteranterm·key websites and academic centers. For the Israel study, inclusion criteria were at least 20 years of age, currently or formerly serving in a combat unit of the Israeli Defense Forces, and service in the last 20 years.

The order of surveyterm·mth scales was randomized in two unique iterations that participants were assigned to at random, but both iterations included the MIOSterm·mth as the first scale that participants were required to complete. All state-based measures were indexed to the past month. For the US study only, participants were required to answer all questions in a measure before moving on in the surveyterm·mth via the Qualtrics “Forced Response” option. This method prevented participants from continuing without answering a missed question, which has been shown not to affect the reliability of online surveysterm·mth ( 40 ). Therefore, there were no missing responses in the final US dataset, except for one question that asked participants to write-out their PMIEterm·dom if they felt comfortable. Only surveyterm·mth completers were included in the final dataset for each country.

After the other Stage III data were collected, our Israeli partners examined the test-retest reliability of the final MIOSterm·mth. The Ruppin Academic Center IRB approved the study. The same inclusion criteria as the Israeli Stage III study were applied and the demographics of the study group were similar. Eighteen SMs and Veteransterm·key completed the MIOSterm·mth twice, a week apart.

Measures Tests of Convergent Validity Mental and Behavioral Health.

Depression symptom severity was measured with the nine-item Patient Health Questionnaire [PHQ-9; ( 41 )]. Participants endorsed items on a 4-point frequency scale (0 = not at all to 3 = nearly every day ) about their depressive symptoms in the last 14 days. Item responses were summed, with higher scores reflecting greater severity of depression symptoms. The PHQ-9 is the most used depression measure and has very strong internal consistency reliability and validity [α = 0.89; ( 42 )]. PTSDterm·key symptom severity over the past 30 days was assessed with the 20-item PTSDterm·key Checklist for the DSM-5 [PCL-5; ( 43 )]. Items were endorsed on a 5-point scale (0 = not at all to 4 = extremely ). Item responses were summed, with higher scores representing greater PTSDterm·key symptom severity. The PCL-5 has been shown to be highly reliable and valid [α = 0.94; ( 43 )]. Functional impairment was assessed with the B-IPF ( 38 ) at the end of the MIOSterm·mth.

Moral Emotions.

State guilt and shameterm·dom were assessed with the 10-item version of the State Guilt and Shameterm·dom Scale [SGSS; ( 44 )]. Participants endorsed items on a 5-point scale (1 = not feeling this way at all to 5 = feeling this way very strongly ). Item responses were summed to create a total score for state guilt and shameterm·dom. The SGSS has been shown to be reliable and valid [α = 0.85; ( 44 )]. We also used a short 16-item version of the Trauma-related Guilt Inventory [TRGI; ( 45 )]. The TRGI was developed to assess guilt feelings and attitudes about a specific traumatic event. The brief TRGI yields three averaged subscale scores: Hindsight-bias/responsibility, assessing self-blame and beliefs the event should have been prevented (seven items; Cronbach's α = 0.89); Wrongdoing, assessing perceived transgression in behavior, thoughts, and emotions (five items; Cronbach's α =0.73); and Lack of Justification, assessing the inability to justify actions (four items; Cronbach's α = 0.83). The TGRI scale has high internal consistency and test-retest reliability ( 45 ). Finally, we administered the 5-item Dimensions of Angerterm·dom Reactions [DAR-5; ( 46 )] as a brief measure of state angerterm·dom. Participants endorsed items on a 5-point scale (1 = almost none of the time to 5 = all or almost all of the time). Item responses were summed to create a total angerterm·dom score, with higher scores representing greater angerterm·dom levels. The DAR-5 has been shown to have convergent validity and is highly reliable [α = 0.97; ( 46 )].

Religion and Spirituality.

Religious and spiritual struggles were assessed with an eight-item version of the Religious and Spiritual Struggles Scale [RSS; ( 47 )]. Participants endorsed items on a 5-point scale (1 = not at all to 5 = a great deal ). Item responses were summed to create a total score for religious and spiritual struggles, with higher scores indicating greater struggles. The RSS has been found to be reliable and has good convergent, discriminant, and predictive validity [α = 0.87; ( 47 )].

Moral Injuryterm·dom.

To assess MIterm·dom as an outcome, we used the 17-item Expressions of Moral Injuryterm·dom Scale—Military Version [EMIS-M ( 5 )]. Participants endorsed items on a 5-point scale (1 = strongly disagree to 5 = strongly agree ). Item responses were summed to create a total score.

Results Descriptive Statistics The sociodemographic and military service characteristics of the US, Australian, and Israeli groups are shown in a Table in the Supplementary Material . In the US study, the group was predominantly white men, with a modal age range of 30–39 (to enhance anonymity, we used age rages rather than age), and ~24% were active-duty SMs. All US participants served in the Iraq or Afghanistan Wars (primarily deployed between 2001 and 2010) and the majority had combat arms duty while serving, which means that the majority participated in tactical ground combat and likely entailed multiple exposures to high magnitude warzone stressors and potentially traumatizing and morally injurious events. This is atypical for US Veteranterm·key surveyterm·mth studies that generally have majorities of service support personnel with substantially less combat exposure ( 4 ). By contrast, the Australia study group was substantially older [modal age range = 40–59 [17.3% were 60–79)]; 25% were never deployed to a warzone and, although 54.3% endorsed deploying to a “warlike” context, which unfortunately leaves unspecified the types of roles within that context, 79% reported being deployed in their careers in peacekeeping, humanitarian, and border protection missions, which are missions typically associated with bearing witness to others' transgressions and grotesque harm to others ( 48 ). Ninety-one percent of the Israeli participants were Veteransterm·key, the majority were male (75%), and 90% were in the 20–29 age range (substantially younger than both other cohorts).

Means and standard deviations for all scales for the PMIE-endorsers in all studies are reported in Table 6 . Internal consistency values of the MIOSterm·mth were strong across all samples, with Cronbach's alphas ranging from 0.88 (TVR) to 0.95 (total) in the US sample, 0.83 (TVR) to 0.89 (total) in the Australian sample, and 0.83 (TVR) and 0.90 (total) in the Israeli sample. Because the sample size was sufficient, we conducted a CFA to confirm the two-factor structure of the MIOSterm·mth in the US Phase III sample (see Supplementary Material ).

MIOSterm·mth total and subscale descriptives and correlations across all phase III sample PMIE-endorsers.

The types of PMIEsterm·dom endorsed and the PTSDterm·key screener results for the PMIE-endorsers for each study (and non-endorsers for the US and Israeli studies) are presented in a Supplementary Table . In the US study, 73.1% of PMIEterm·dom endorsers reported at least one PMIEterm·dom related to the self, 80% endorsed at least one PMIEterm·dom related to another, and 84.3% endorsed at least one betrayal event. When asked to endorse the worst and most currently distressing PMIEterm·dom (using a forced choice), 45.7% endorsed a self-transgression (32.9 and 21.4% endorsed PMIE-other and PMIE-betrayal, respectively). In addition, 82.2% of the US participants' worst and most currently distressing PMIEsterm·dom met Criterion-A (the PMIEterm·dom was reported to involve actual or threatened death, serious injury, or sexual violence), and 52.1% of PMIE-endorsers that met Criterion-A endorsed 4 or 5 PTSDterm·key screener items (26.4% and 25.7%, respectively), and thus likely had clinically significant PTSDterm·key symptoms as a putative result of the PMIEterm·dom or the context in which the PMIEterm·dom occurred; 4/5 screener items endorsed is the most diagnostically efficient; 5/5 is the most specific ( 21 ) [in this group, the Mean PCL-5 score was 55.72 (SD = 17.7)]. Yet, in the US sample, there were no differences in the percentage of PMIE-endorsers whose event was not a Criterion-A trauma (which formally eliminates the possibility of PTSDterm·key caseness) who endorsed 4 or 5 PTSDterm·key screener items, relative to those who endorsed Criterion-A [the Mean PCL-5 score for this subgroup was 53.90 (SD = 19.45); mean difference (95% CI): 1.82 (−7.66, 11.30), p < 0.695]. In the Australia study, 45.1% of participants endorsed a history of exposure to at least one PMIE-self event, 74.7% endorsed at least one MI-other event, and 79.1% endorsed at least one PMIE-betrayal event. When asked to endorse the worst and most currently distressing PMIEterm·dom, 83.9% endorsed PMIE-other or PMIE-betrayal (non-self-PMIEs). In addition, 60% of the Australia participants' worst and most currently distressing PMIEsterm·dom met Criterion-A, and 56.3% endorsed 4 or 5 PTSDterm·key screener items. In the Israeli study, 63.4% of participants endorsed a history of exposure to at least one PMIE-self event, 60.6% endorsed at least one MI-other event, and 21.1% endorsed at least one PMIE-betrayal event. When asked to endorse the worst and most currently distressing PMIEterm·dom, 38% endorsed PMIE-self, 39.4% a PMIE-other event, and 22.5 endorsed a PMIE-betrayal event. In addition, 38% of the Israeli participants' worst and most currently distressing PMIEsterm·dom met Criterion-A, and 11% endorsed 4 screener items (none endorsed 5).

Test-Retest Reliability Bland-Altman Limits of Agreement [LOA; ( 49 )] were calculated to assess test-retest reliability ( n = 17). LOA use descriptive statistics for paired data to represent upper and lower boundaries of the middle 95% range of observed within-pair differences, centered around the mean within-pair difference. Confidence intervals (95%) are calculated around the upper and lower limits to improve inference beyond the sample. LOA are preferable to correlation analyses when determining test-retest reliability, as correlation analyses may conceal systematic bias ( 50 ). LOA uses an a priori determination of acceptable within-pair difference; for the MIOSterm·mth we determined this to be ±14, which represents a within-pair difference of ±1 on all MIOSterm·mth items. After removing an outlier, the LOA's and the upper and lower 95% CIs were −8.62 (−12.83 to −4.41) to 9.12 (4.91 to 13.34), which were within acceptable limits to establish test-retest reliability and the bias estimate was small β = 0.25.

Convergent Validity: MIOSterm·mth Total and Subscale Scores Table 6 depicts the Pearson correlations for PMIEterm·dom endorsers between MIOSterm·mth total and subscale scores and Stage III measures in the US, Australian, and Israeli samples. The intercorrelations of all variables for PMIE-endorsers and non-endorsers (only for US and Israel studies which had sufficient Ns) are presented in Supplementary Material . We used procedures developed by Meng et al. ( 51 ) to examine contrasts between correlated associations to test hypotheses. In each sample, as predicted, MIOSterm·mth total and subscale scores were strongly correlated with measures of mental and behavioral health (PTSDterm·key, depression, and functional impairments). Although, in the US study, these correlations were substantially higher, they were no higher than the correlations between the PCL-5 and the PHQ-9 and B-IPF (Z-scores for these three contrasts were NS).

Convergent Validity: MIOSterm·mth Subscale Scores As can be seen in Table 7 , as predicted, in each sample, MIOSterm·mth SR subscale scores were more strongly correlated with the TRGI and the SSGS, relative to the TVR subscale. In the US sample, MIOSterm·mth SR subscales scores were more correlated with RSS scores, relative to TVR subscale scores. Contrary to our prediction, across all samples, the SR and TVR subscales were equally correlated with the DAR scores.

Convergent validity contrasts by MIOSterm·mth shame-relatedterm·dom and trust violation-related subscale scores.

MIOSterm·mth Score Differences Between PMIEterm·dom Endorsers and Non-endorsers As predicted, in the US study, the group that did not endorse a PMIEterm·dom had significantly lower MIOSterm·mth total and SR and TVR subscale scores ( M = 20.90, SD=13.37; M = 9.92, SD = 6.86; M = 10.97, SD = 6.79, respectively) than the group who endorsed a PMIEterm·dom [ M = 33.58, SD = 13.37; t (418) = −7.25, p < 0.001; M = 16.50, SD = 7.27; t (418) = −6.97, p < 0.001; M = 17.07, SD = 6.62, t (418) = −7.01, p < 0.001, respectively]. The magnitude of the differences in scores between these two groups was substantial, as indicated by very large Cohen's d effect sizes (0.91–0.95; the Australian study did not have enough non-PMIE endorsers to conduct this analysis). In the Israeli study, the group that did not endorse a PMIEterm·dom had significantly lower MIOSterm·mth total and SR and TVR subscale scores ( M = 5.95, SD=6.80; M = 2.45, SD = 3.78; M = 3.50, SD = 3.78, respectively) than the group who endorsed a PMIEterm·dom [ M = 14.55, SD = 9.28; t (109) = 5.13, p < 0.001; M = 5.96, SD = 5.20; t (109) = 3.74, p < 0.001; M = 8.59, SD = 5.25, t (109) = 5.39, p < 0.001, respectively]. These differences were also substantial (effect sizes 0.77 to 1.19). Moreover, there were substantial differences in B-IPF scores that were indexed to MIOSterm·mth symptoms among PMIE-endorsers and non-endorsers in the US study [endorsers: 70.51, SD=25.36 vs. non-endorsers: 48.89 SD = 33.06; mean difference (95% CI): 21.63 (14.54, 28.71), p < 0.001] and the Israeli study [endorsers: 22.96, SD=24.84 vs. non-endorsers: 8.06 SD = 23.25; mean difference (95% CI): 14.91 (5.34, 24.28), p < 0.003]. This suggests that PMIE-endorsement is associated with markedly greater impairments indexed to MIOSterm·mth items, relative to impairments indexed to MIOSterm·mth symptoms indexed to a non-PMIE stressor.

Discussion There has been an explosion of interest in MIterm·dom in healthcare, mental health, the media, in and outside the military and organizations that address the behavioral health needs of Veteransterm·key, and various scholarly and applied disciplines. Unfortunately, acceptance of the idea of MIterm·dom has outpaced scientific knowledge, yet, in many contexts, the concept of MIterm·dom is reified. This is particularly problematic because there are widely varying uses of the MIterm·dom term, which is not surprising given that there has been no agreement about the boundary conditions of the MIterm·dom syndrome. Existing empirical studies have also used imprecise terminology and have been hampered by a lack of a gold standard of measurement. In addition, treatments have been developed to putatively target MIterm·dom, which is cart before the horse without a definition of the MIterm·dom syndrome, a case definition, and a way to assess efficacy.

We aimed to redress these problems by using theory and multinational bottom-up phenomenological evaluations of the impact of exposure to PMIEsterm·dom to operationalize the syndrome of MIterm·dom into constituent domainsterm·mth of impact of PMIEsterm·dom. We then used the definitions of the domainsterm·mth of impact (and components with each domainterm·mth) to create a psychometrically sound measure of MIterm·dom (indexed by reports of exposure to a worst and most currently distressing PMIEterm·dom), that could be used in clinical and research settings to identify functionally impairing MIterm·dom, and to track change. We generated content for the MIOSterm·mth from multinational interviews with SMs and Veteransterm·key who were asked to describe how exposure to their worst PMIEterm·dom changed their beliefs, emotions, and behaviors, as well as with mental and spiritual health care-providers asked to describe the problems and struggles of individuals with MIterm·dom, ensuring strong cross-country content validityterm·mth (albeit in English-speaking countries). The final 14-item MIOSterm·mth was found to be highly reliable and had a robust two-factor structure, entailing SR and TVR items (7-items each). The MIOSterm·mth also had partial scalar invariance across nations.

In Stage II and III, the correlations between the MIOSterm·mth subscales were moderate, suggesting that SR and TVR are separable but related subconstructs of MIterm·dom. However, the correlation was high in the US Stage III sample, suggesting that the subscales may have substantially less discrimination. A possible explanation is that for the US sample, current MI-related problems are a gestalt blend of SR and TVR symptoms among SMs and Veteransterm·key with direct combat roles and high combat exposure, very high rates of at least one self- and other-related PMIEterm·dom, and high rates of PMIEsterm·dom that were associated with life-threat or the loss of life (unlike individuals evaluated in Stage I and II, and unlike the other Stage III study groups). This hypothesis would be equally germane to other contexts [e.g., refugees who suffer chronic political violence and traumatic trust violations in their home country and who do things or fail to do things that violate their deeply held moral beliefs to survive passage to a putatively safer country; ( 52 )]. It should be noted that in population studies of US Veteransterm·key, PTSDterm·key subclusters are also very highly correlated [e.g., in one study, the reexperiencing subcluster was correlated 0.795 with the negative alterations in cognitions and mood subcluster; ( 53 )]. If additional research also shows that MIOSterm·mth subscales are highly correlated among individuals with multiple exposures to traumas and both self- and other-PMIEs, MIOSterm·mth total scores may be the only valid index of MIterm·dom in these contexts (clinically, the recommendation would be to interview the person further to determine whether there is a pressing and most currently distressing event and domainsterm·mth of impact applicable to that event).

The convergent validity findings for MIOSterm·mth total and subscale scores were consistently strong. Across Stage III studies, there were consistently large associations between indicators of mental and behavioral health and functional impairments and MIOSterm·mth total and subscale scores. This is consistent with the theory that posits that some PTSDterm·key (e.g., reexperiencing, avoidance, detachment) and depression symptoms (dysphoria, hopelessness, anhedonia) are associated with exposure to any type of PMIEterm·dom and are de facto aspects of the MIterm·dom syndrome ( 1 ). As stated above, we purposely generated content for the MIOSterm·mth that was distinct from the overlapping features of PTSDterm·key and depression that were endorsed by Stage I participants, and we assume that the resulting domainsterm·mth of impact, reflected in MIOSterm·mth content, are core drivers of MIterm·dom and will prove to be beneficial targets of treatment for functionally impairing MIterm·dom.

The differential convergent validity predictions for the MIOSterm·mth subscales were partially confirmed. Relative to the TVR subscale, SR subscale scores were consistently more strongly correlated with constructs that measure guilt and shameterm·dom. And, in the US Stage III sample, as predicted, religious and spirituality struggle scores were more strongly correlated with SR subscale than TVR subscale scores. However, in each Stage III study, there were no differences between the association of TVR and SR scores with DAR-5 scores. This suggests that either TVR symptoms do not have separable construct validity, or the moral emotion of angerterm·dom (and associated aggressive behaviors) is a shared element of SR and TVR outcomes from exposure to any type of PMIEterm·dom among SMs and Veteransterm·key. Future research is needed to examine each of these possibilities and examine other unique convergent indicators of TVR scores (e.g., distrust, alienation, embitterment, grievance).

We demonstrated that PMIEterm·dom endorsement was associated with substantially higher scores on the MIOSterm·mth and greater functional impact relative to another type of stressor. This validates the foundational assumption that MIterm·dom is a PMIE-linked problem . Generally, most participants had low or moderate scores. The is consistent with the hypothesis that clinically significant MIterm·dom is a low-baserate problem ( 8 ). For epidemiological and clinical studies, future research will need to empirically test the predictive and clinical validity of variations in case definitions for MIterm·dom, potentially using a combination of type of PMIEterm·dom and threshold MIOSterm·mth and functional impact scores, particularly as a means of distinguishing non-clinical levels of moral distress from MIterm·dom ( 13 ). It is an empirical question whether requiring a PMIEterm·dom to be a Criterion-A event or to occur in a life-threat context (or including positive endorsement of certain types of PTSDterm·key screener items) will improve the utility of a case definition. Perhaps more importantly, future research will need to test the incremental validity of MIOSterm·mth scores, relative to PTSDterm·key symptoms indexed to a PMIEterm·dom that meets or does not meet Criterion-A, as well as depression. In the US Stage III study, MIOSterm·mth scores were particularly highly correlated with PTSDterm·key and depression, which suggests that when individuals are exposed to multiple types of PMIEsterm·dom that occur in an enduring life-threat context the critical assessment task will be to determine if there is a worst and most currently distressing event that results in substantial impairment. Even when PTSDterm·key is the treatment focus, we predict that treatment will be impacted by impairing MIterm·dom symptoms, which may require separate attention.

Although our study had unprecedented depth, it had limitations. First, although Stage I took 3 years to complete and entailed teams of clinical researchers in different countries, the qualitative results may have been different had an independent team of content experts examined the data and generated domainterm·mth definitions. We also could have been more systematic about getting feedback about MIOSterm·mth items and the MIOSterm·mth from stakeholders. Second, although we used reputable surveyterm·mth firms who had established panels of SMs and Veteransterm·key, we cannot rule out the possibility that some responders may have provided different responses if interviews were conducted. Thankfully, research has shown that online responses do not substantively differ from paper and pencil and telephone-interview-based responses ( 54 , 55 ). Also, for Stage III, we reduced the likelihood of fatigue and disengagement affecting test responses by randomly assigning test order. Finally, we found that participants had a sizable percentage of N/A entries for B-IPF scores, suggesting that, although there was a good deal of missing data in the Israeli and Australia studies, Stage III participants were not careless.

We anticipate that a wealth of research about the prevalence and predictors of MIterm·dom will flourish using the MIOSterm·mth and intervention studies will for the first time be able to track change using the MIOSterm·mth. We also welcome clinicians using the MIOSterm·mth to plan treatment and track clinical change over the course of treatment, which has been a missing link in any intervention approach that presumably targets MIterm·dom. Yet, there are unaddressed empirical issues that arise from this study, some of which were described above. First, our results should be replicated with other samples, particularly among civilians and various occupational and non-English-speaking cultures. Second, research is needed to test the discriminant validity of the MIOSterm·mth, which our group is planning to do. It will be important to examine the association between MIOSterm·mth subscale scores and externalizing (including a cynical world view) and internalizing traits, given that it seems possible that externalizing would increase risk for exposure to TVR experiences and outcomes and internalizing would increase risk for exposure to SR experiences and outcomes. Finally, given that the studies described in this paper were all cross-sectional, future research should examine the causal direction between exposure to PMIEsterm·dom and MIOSterm·mth scores as well as the direction of the associations between converging indicators and MIOSterm·mth scores.

Data Availability Statement The raw data supporting the conclusions of this article will be made available by the authors, once approved by the respective internal review boards.

Ethics Statement The studies involving human participants were reviewed and approved by VA Boston Healthcare System IRB, Australian Departments of Defense and Veteransterm·key' Affairs Human Research Ethics Committee, Western University HSREB, Royal Ottawa Research Ethics Board, Combat Stress Research Committee, and Ruppin Academic Center IRB. The patients/participants provided their written informed consent to participate in this study.

Moral Injury Outcome Scaleterm·mth Consortium Andrea Ashbaugh 1 , Julie Yeterian 2 , Danielle Berke 3 , Jessica Carney 4 , Mackenzie Cummings 5 , Ruth Chartoff 6 , Stephanie Ellickson-Larew 6, 7 , Breanna Grunthal 6 , Maya Bina N. Vannini 6 , Frank Weathers 8 , Luke Rusowicz-Orazem 6, 9 , Patrick Smith 10 , Fardous Hosseiny 10 , Lisa King 11 , J. Don Richardson 11−14 , Alexandra McIntyre-Smith, David Forbes 15, 16 , Kim Jones 15 , Ellie Lawrence-Wood 15 , Kelsey Madden 15 , Kim Murray 15 1 University of Ottawa, Ottawa, ON, Canada, 2 William James College, Newton, MA, United States, 3 Hunter College of the City University of New York, New York, NY, United States, 4 University of Notre Dame, Notre Dame, IN, United States, 5 Seattle Pacific University, Seattle, WA, United States, 6 VA Boston Healthcare System, Boston, MA, United States, 7 National Center for PTSDterm·key, Boston, MA, United States, 8 VA Puget Sound Healthcare System, Seattle, WA, United States, 9 School of Public Health, Boston University, Boston, MA, United States, 10 Atlas Institute for Veteransterm·key and Families, Ottawa, ON, Canada, 11 Operational Stress Injury Clinic, Parkwood Institute, London, ON, Canada, 12 Franklin OSI Research Centre, Lawson Health Research Institute, London, ON, Canada, 13 Department of Psychiatry, Western University, London, ON, Canada, 14 Department of Psychiatry, McMaster University, Hamilton, ON, Canada, 15 Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, Carlton, VA, Australia, 16 University of Melbourne, Melbourne, VA, Australia Author Contributions BL was the principal investigator, oversaw all aspects of data collection and analysis and principal writer of the manuscript. RP and AN analyzed data and co-wrote the manuscript. DM co-wrote the manuscript. AP helped secure funding and co-wrote the manuscript. AC analyzed the qualitative data and helped generate the MIOSterm·mth and edited the manuscript. SH, LD, SF, GZ, and YL-B collected data, helped generate the scale, and co-wrote the manuscript. All authors contributed to the article and approved the submitted version.

Funding MIOSterm·mth consortium activities were supported in part by VA Cooperative Studies Program, Office of Research and Development, US Department of Veteransterm·key Affairs; Department of Veteransterm·key' Affairs Australia, Phoenix Australia - Center for Posttraumatic Mental Health; and the Canadian Center of Excellence on PTSDterm·key and Related Mental Health Conditions.

Conflict of Interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Contributor Information The Moral Injury Outcome Scaleterm·mth Consortium: Andrea Ashbaugh , Julie Yeterian , Danielle Berke , Jessica Carney , Mackenzie Cummings , Ruth Chartoff , Stephanie Ellickson-Larew , Breanna Grunthal , Maya Bina N. Vannini , Frank Weathers , Luke Rusowicz-Orazem , Patrick Smith , Fardous Hosseiny , Lisa King , J. Don Richardson , Alexandra McIntyre-Smith David Forbes , Kim Jones , Ellie Lawrence-Wood , Kelsey Madden , and Kim Murray Supplementary Material The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2022.923928/full#supplementary-material Click here for additional data file.

References Associated Data Supplementary Materials Click here for additional data file.

Data Availability Statement The raw data supporting the conclusions of this article will be made available by the authors, once approved by the respective internal review boards.