Home > Public Resources > Trauma Blog > 2020 - May > Trauma and Diversity: Moral Injury Among Justice-Involved Veterans: An Understudied Clinical Concern Trauma and Diversity: Moral Injury Among Justice-Involved Veterans: An Understudied Clinical Concern W. Blake Martin, Ryan Holliday and James P. LePage May 4, 2020 While the concept of moral injury has existed for years, moral injury has received increased empirical attention over the past decade. Many definitions of moral injury exist; however, one of the most commonly used is by Litz and colleagues (2009) who define moral injury as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Moreover, Litz et al. note that potentially morally injurious events (PMIEs) can occur in a number of forms such as committing an act of wrongdoing, failing to prevent unethical behavior, or witnessing or learning about an event. While there is a growing body of evidence examining moral injury in U.S. military service members and veterans, to date studies of moral injury have largely focused on combat personnel and veterans’ beliefs about their own goodness and goodness of the world (Griffin et al., 2019). While important, such a focus limits understanding of important subsets of this population in need of increased empirical attention. Indeed, a recent integrative review by Griffin and colleagues (2019) called for the examination of moral injury in novel populations such as justice-involved individuals. As such, we propose that moral injury may be a factor affecting justice-involved individuals and may be particularly salient among justice-involved veterans (JIVs). Veterans and Justice Involvement JIVs currently comprise approximately 8% of the incarcerated U.S. population, with over 180,000 veterans estimated to be in prisons or jails and a far greater number currently on parole or probation (Bronson, Carson, Noonan, & Berzofsky, 2015). Furthermore, JIVs appear to experience heightened risk for negative sequelae such as homelessness, suicide, unemployment and psychiatric diagnoses (Blodgett et al., 2015; Finlay et al., 2019; Holliday et al., 2020; Wortzel, Binswanger, Anderson, & Adler, 2009). While various factors may contribute to these negative outcomes, the potential for exposure to PMIEs during justice involvement and the resulting distress has not yet been examined in this population. Moral Injury Specific to Involvement with the Criminal Justice System The circumstances leading to incarceration (e.g., engaging in criminal activity), interactions with the U.S. justice system, the environment of prison itself, and the subsequent challenges faced by justice-involved individuals upon release all provide ample opportunity for PMIEs to occur. In drawing a comparison to PMIEs in combat veterans, we suggest several analogs to experiences that JIVs may endure during the course of justice involvement. Justice involvement may provide unique circumstances in which individuals may witness and/or enact behaviors that may violate deeply held beliefs about the self and the world. There are multiple ways in which justice involvement may create opportunities for PMIEs to occur. For example, committing a criminal act may represent a PMIE, particularly among offenses that are violent in nature and involve harm to another individual. Moreover, the process of being convicted and charged with an offense may serve as a powerful reminder of the PMIE and tie this event to the individual’s identity and future. Furthermore, the physical and social environment of prison itself (e.g., being behind bars, being surrounded by other offenders) may be a result, a reminder and an associated consequence of the morally injurious event as well as increasing the likelihood of being exposed to or participating in additional PMIEs (e.g., witnessing or experiencing physical violence while incarcerated). For example, alleged incidents of sexual victimization were found at a rate of 11 per 1,000 inmates (Rantala, 2018). This is compared to 2.7 per 1,000 in the general population (Morgan & Oudekerk, 2019), though it must be acknowledged that these reports had differing methodological and reporting procedures. These experiences and environments also potentially create risks for subsequent PMIEs to occur (e.g., engaging in or witnessing violence after release, increased risk for recidivism; Blonigen et al., 2016). The consequences of PMIEs in the context of justice involvement may also have bearing on another touchstone of moral injury: changes in one’s schema of the self and world. While the social-cognitive model of PTSD suggests that beliefs related to self-efficacy and competency may be threatened by traumatic events, moral injury may result in deeper and more global changes in beliefs about the self (Benight & Bandura, 2004; Litz et al., 2009). For example, moral injury may result in a belief that the self is immoral, irredeemable and/or that the world is immoral (Litz et al., 2009). This in turn may drive the commonly seen cognitive-affective sequelae (e.g., guilt, shame) among those who have experienced PMIEs (Bryan, Morrow, Etienne, & Ray-Sannerud, 2013). At a societal level, JIVs by definition are deemed “guilty” and are thus culpable for their offense, leading to reinforcing a negative change in one’s view of self and the world. In line with identity theory, external, negative appraisals about a JIV (e.g., they are a danger to society, they cannot be trusted to do the right thing) may influence a JIV’s self-perception (Asensio & Burke, 2011). Furthermore, affective characteristics often found in the context of moral injury include guilt, shame, anger, disgust and contempt (Litz et al., 2009). These domains may be exacerbated by the experience of justice involvement, as personal feelings of guilt and shame may be reinforced by similar messages via their verdict and sentence as well as the perceptions of verdict and sentence by those around them (e.g., social support system). This concern may be especially salient in JIVs, as the positive social identity of veteran status conflicts with the stigma that accompanies justice involvement (Atkin-Plunk & Sloas, 2018). In general, JIVs incur increased risk for experiencing opportunities for moral injury due to the potential for exposure to PMIEs across multiple time points (e.g., prior to military service, during military service, arrest, during imprisonment and post-incarceration). Furthermore, the stigma that accompanies justice involvement may limit access to treatment and/or a willingness to seek treatment for distress related to PMIEs. Additionally, PMIEs and associated deleterious effects that go unaddressed may compound over time and, in turn, have the propensity to potentially exacerbate psychosocial functioning and thus increase risk for psychosocial stressors (e.g., homelessness) and mental health symptoms. The focus of moral injury and its impact on perception of the world and self is a cogent and important line of inquiry for several reasons. First, in contrast with static risk factors such as exposure to prior adverse events or family mental health history, sequelae of PMIEs may be targetable through treatment. Trauma-focused psychotherapies (e.g., cognitive processing therapy, prolonged exposure therapy) may have merit in helping veterans who have experienced morally injurious events (Held, Klassen, Brennan, & Zalta, 2018). Treatments have also been developed or modified to help survivors of PMIEs (e.g., adaptive disclosure, acceptance and commitment therapy, impact of killing; Borges, 2019; Farnsworth et al., 2017; Gray et al., 2012; Maguen et al., 2017). While there is currently a small body of research examining interventions focused on addressing the sequelae of moral injury (e.g., guilt, shame), early findings suggest these factors are malleable and responsive to treatment (Gray et al., 2012; Griffin et al., 2019). Conclusions and Next Steps As no studies have examined the experience and impact of moral injury in JIVs, an initial step would be to develop and then test a theoretical model of moral injury specific to this group. Given the limited prior research, this would require a mixed-method approach. Specifically, an initial examination of the lived experience of JIVs to elucidate factors idiographic to this population is warranted. Though logical analogs between JIVs and combat veterans exist (Table 1), these have yet to be empirically examined. Furthermore, this line of inquiry would facilitate identifying if existing measures of exposure to PMIEs and the impact of these events, such as the Moral Injury Events Scale and Moral Injury Questionnaire (Currier, Holland, Drescher, & Foy, 2015; Nash et al., 2013), validly capture the experience of moral injury germane to this population. Should additional revision be warranted, qualitative methodology could infer necessary items to add to existing measures to ensure adequate measurement of moral injury experience among JIVs. Once developed, these measures could be used to identify JIVs who are experiencing distress due to experiencing a PMIE and subsequently route these individuals for appropriate treatment. Furthermore, moral injury may be a particularly salient and relevant factor impacting psychosocial functioning among JIVs. For example, JIVs may avoid reminders of the morally injurious event and associated distress by withdrawing from relationships, the workforce and/or mainstream society (Houtsma, Khazem, Green & Anestis, 2016). As a result, individuals may not be exposed to corrective experiences that ameliorate the impact of PMIEs (e.g., the individual can do good, the individual can be accepted, the world is not always amoral; Litz et al., 2009). Finally, accurate measurement may facilitate the ability to quantitatively test the role of PMIEs in affecting JIVs’ psychiatric symptoms and functioning. Increased understanding can further inform conceptualization of moral injury among JIVs as well as the potential moderating role of moral injury in psychiatric symptoms and suicide risk. An additional important step would be to determine whether current interventions to address the impact of moral injury (e.g., adaptive disclosure, acceptance and commitment therapy, impact of killing) or trauma-focused psychotherapies (e.g., cognitive processing therapy, prolonged exposure therapy) are feasible and effective with JIVs in attenuating the sequelae that follow a morally injurious event. Indeed, JIVs may experience a myriad of factors that can impact the treatment process (Slattery, Dugger, Lamb & Williams, 2013). Therefore, future research should investigate which time points for intervention (e.g., during incarceration, just before release, following release from prison) may be the most feasible and effective for delivering an intervention. Additionally, effectively addressing the consequences of moral injury may have added utility in addressing other psychosocial concerns (e.g., mental health burden, barriers to employment and housing, social connection). Available evidence, while limited, suggests that JIVs may be a group at risk for experiencing morally injurious events. However, to date there has been no research specifically examining the construct of moral injury in this population. Future research remains necessary to ensure justice-involved veterans receive optimal assessment and treatment of moral injury. About the Authors: Ryan Holliday is a clinical research psychologist and investigator in the Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention and an assistant professor at the University of Colorado Anschutz Medical Campus. He is interested in better understanding how the role of psychosocial stressors and trauma intersect to increase suicide risk. Blake Martin is a graduate research assistant at the VA North Texas Health Care System and a doctoral candidate in clinical psychology at The University of Texas Southwestern Medical Center. His research interests include suicide prevention in populations with increased risk and examining modifiable factors that may protect against suicidal self-directed violence. James P. LePage is a clinical psychologist, the associate chief of staff for research and development at the VA North Texas Health Care System, and a professor at The University of Texas Southwestern Medical Center. His research interests focus on developing interventions for psychosocial rehabilitation with vulnerable populations. He is also interested in psychological test development and evaluation. References Asencio, E. K., & Burke, P. J. (2011). Does incarceration change the criminal identity? A synthesis of labeling and identity theory perspectives on identity change. Sociological Perspectives, 54(2), 163-182. https://doi.org/10.1525/sop.2011.54.2.163 Atkin-Plunk, C. A., & Sloas, L. B. (2019). Support for balanced justice and rehabilitation for justice-involved veterans. Criminal Justice Review, 44(2), 165-182. https://doi.org/10.1177/0734016818793698 Benight, C. C., & Bandura, A. (2004). Social cognitive theory of posttraumatic recovery: The role of perceived self-efficacy. Behaviour Research and Therapy, 42(10), 1129-1148. https://doi.org/10.1016/j.brat.2003.08.008 Blodgett, J. C., Avoundjian, T., Finlay, A. K., Rosenthal, J., Asch, S. M., Maisel, N. C., & Midboe, A. M. (2015). Prevalence of mental health disorders among justice-involved veterans. Epidemiologic Reviews, 37(1), 163-176. https://doi.org/10.1093/epirev/mxu003 Blonigen, D. M., Bui, L., Elbogen, E. B., Blodgett, J. C., Maisel, N. C., Midboe, A. M., … Timko, C. (2016). Risk of recidivism among justice-involved veterans: A systematic review of the literature. Criminal Justice Policy Review, 27(8), 812-837. https://doi.org/10.1177/0887403414562602 Borges, L. M. (2019). A service member’s experience of Acceptance and Commitment Therapy for Moral Injury (ACT-MI) via telehealth: “Learning to accept my pain and injury by reconnecting with my values and starting to live a meaningful life.” Journal of Contextual Behavioral Science, 13, 134-140. https://doi.org/10.1016/j.jcbs.2019.08.002 Bronson, J., Carson, A., Noonan, M., & Berzofsky, M. (2015). Veterans in prison and jail, 2011-12. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. NCJ 249144 Currier, J. M., Holland, J. M., Drescher, K., & Foy, D. (2015). Initial psychometric evaluation of the Moral Injury Questionnaire—Military version. Clinical Psychology & Psychotherapy, 22(1), 54-63. https://doi.org/10.1002/cpp.1866 Farnsworth, J. K., Drescher, K. D., Evans, W., & Walser, R. D. (2017). A functional approach to understanding and treating military-related moral injury. Journal of Contextual Behavioral Science, 6(4), 391-397. https://doi.org/10.1016/j.jcbs.2017.07.003 Finlay, A. K., Owens, M. D., Taylor, E., Nash, A., Capdarest-Arest, N., Rosenthal, J., Blue-Howells, J., Clark, S., & Timko, C. (2019). A scoping review of military veterans involved in the criminal justice system and their health and healthcare. Health & Justice, 7(1), 6. https://doi.org/10.1186/s40352-019-0086-9 Gray, M. J., Schorr, Y., Nash, W., Lebowitz, L., Amidon, A., Lansing, A., Maglione, M., Lang, A.J., & Litz, B. T. (2012). Adaptive Disclosure: An open trial of a novel exposure-based intervention for service members with combat-related psychological stress injuries. Behavior Therapy, 43(2), 407-415. https://doi.org/10.1016/j.beth.2011.09.001 Griffin, B. J., Purcell, N., Burkman, K., Litz, B. T., Bryan, C. J., Schmitz, M., Villierme, C., Walsh, J., & Maguen, S. (2019). Moral injury: An integrative review. Journal of Traumatic Stress, 32(3), 350-362. https://doi.org/10.1002/jts.22362 Held, P., Klassen, B. J., Brennan, M. B., & Zalta, A. K. (2018). Using Prolonged Exposure and Cognitive Processing Therapy to treat veterans with moral injury-based PTSD: Two case examples. Cognitive and Behavioral Practice, 25(3), 377-390. https://doi.org/10.1016/j.cbpra.2017.09.003 Holliday, R., Martin, W. B., Monteith, L. L., Clark, S. C., & LePage, J. P. (2020). Suicide among justice-involved veterans: a brief overview of extant research, theoretical conceptualization, and recommendations for future research. Journal of Social Distress and Homelessness, 1-9. https://doi.org/10.1080/10530789.2019.1711306 Houtsma, C., Khazem, L. R., Green, B. A., & Anestis, M. D. (2017). Isolating effects of moral injury and low post-deployment support within the US military. Psychiatry Research, 247, 194-199. https://doi.org/10.1016/j.psychres.2016.11.031 Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695-706. https://doi.org/10.1015/j.cpr.2009.07.003 Maguen, S., Burkman, K., Madden, E., Dinh, J., Bosch, J., Keyser, J., & Neylan, T. C. (2017). Impact of Killing in war: A randomized, controlled pilot trial. Journal of Clinical Psychology, 73(9), 997-1012. https://doi.org/10.1002/jclp.22471 Morgan, R. E. & Oudekerk, B. A. (2019). Criminal Victimization, 2018. Washington DC: US Department of Justice, Bureau of Justice Statistics, NCJ 253043. Nash, W. P., Marino Carper, T. L., Mills, M. A., Au, T., Goldsmith, A., & Litz, B. T. (2013). Psychometric evaluation of the Moral Injury Events Scale. Military Medicine, 178(6), 646-652. https://doi.org/10.7205/MILMED-D-13-00017 Rantala, R. R. (2018). Sexual Victimization Reported by Adult Correctional Authorities, 2012 – 15. Washington DC: US Department of Justice, Bureau of Justice Statistics, NCJ 251146. Slattery, M., Dugger, M. T., Lamb, T. A., & Williams, L. (2013). Catch, treat, and release: Veteran treatment courts address the challenges of returning home. Substance Use & Misuse, 48(10), 922-932. https://doi.org/10.3109/10826084.2013.797468 Wortzel, H. S., Binswanger, I. A., Anderson, C. A., & Adler, L. E. (2009). Suicide among incarcerated veterans. Journal of the American Academy of Psychiatry and the Law, 37(1), 82-91.