Enhancing the Utility of the Moral Injury Experience Wheel: Manualized Applications for Diverse Contexts.

Moral injury has emerged as an important construct for understanding the distress experienced in the aftermath of a moral violation, initially among combat veterans and increasingly among other populations, such as healthcare workers and first responders. While numerous measures have been validated to assess for exposure to potentially morally injurious events and/or sequelae, additional tools are needed to facilitate nuanced discussion of the experience of moral injury in therapeutic encounters. The Moral Injury Experience Wheel (MIEW; Fleming, 2023) is an infographic instrument that is designed to elicit precise language and help differentiate feelings in an effort to process morally perplexing circumstances. This paper describes the contents and potential clinical applications of a newly developed manual to guide the use of the MIEW. The MIEW and manual are designed to be used independently or alongside existing moral injury interventions. A case study featuring the use of the MIEW and manual demonstrates how the tools can be used in a professional healthcare setting. Recommendations for moral injury care practitioners are provided.

The Moral Injury Experience Wheel: An Instrument for Identifying Moral Emotions and Conceptualizing the Mechanisms of Moral Injury.

This paper introduces an infographic tool called The Moral Injury Experience Wheel, designed to help users accurately label moral emotions and conceptualize the mechanisms of moral injury (MI). Feeling wheels have been used by therapists and clinical chaplains to increase emotional literacy since the 1980s. The literature on the skill of emotion differentiation shows a causal relationship between identifying emotions with specificity and emotional and behavioral regulation. Emerging research in moral psychology indicates that differentiating moral emotions with precision is related to similar regulatory effects. Based on this evidence, it is proposed that increasing moral emotional awareness through use of an instrument that visually depicts moral emotions and their causal links to MI will enhance appraisal and flexible thinking skills recognized to reduce the persistent dissonance and maladaptive coping related to MI. Design of the wheel is empirically grounded in MI definitional and scale studies. Iterative evaluative feedback from Veterans with features of MI offers initial qualitative evidence of validity. Two case studies will show utility of the wheel in clinical settings and present preliminary evidence of efficacy.

Complex Moral Injury: Shattered Moral Assumptions.

An infographic model of moral injury (MI) is introduced in this conceptual paper that distinguishes the development of a worldview discrepancy-induced genus of MI, called complex moral injury (C-MI), from a standard expression of moral injury (S-MI), clearly delineated as perpetration-focused and a violation of moral belief in the contemporary view. It builds upon a previous essay that examined the potential of paradoxical circumstance (e.g., clashes of value, competing moral expectations, and moral paradox) to inflict MI among military personnel during wartime (Fleming in J Relig Health 60(5):3012-3033, 2021). Accordingly, it heeds Litz et al.'s recommendation to expand the research of MI beyond the effects of perpetration and investigate the impact of morally injurious events that shake one's core moral beliefs about the world and self (Litz et al. in Clin Psychol Rev 29(8):695-706, 2009). A review of definitional, scale, and qualitative studies shows evidence of a nuanced and complex form of MI that presents as moral disorientation and is a response to a disruption and subsequent failure of foundational moral beliefs to adequately appraise ethical problems and inform moral identity. Interrelations between MI, assumptive world, and meaning theories suggest the mechanism of C-MI and potential therapies. Case studies from a Veterans Administration hospital in the United States and a walk through the diagram will help illustrate the model. Clinical implications of a definition that includes morally injurious events that shatter fundamental moral assumptions are discussed. The role of chaplains in facilitating acceptance and meaning-making processes is recommended for C-MI recovery. Acknowledging the model's need for empirical support, a plausible scale is discussed for future research.

Moral Injury and the Absurd: The suffering of moral paradox.

Drawing upon qualitative and construct validity evidence within MI research and the oral histories of combat-exposed Veterans, this paper explores the role of moral paradox (MP) as a precondition of moral injury (MI). Research is recommended to clearly delineate MP as a causative factor leading to more intractable cases of MI in the definitional literature, beyond the recognized impact of perpetration and betrayal-based conditions. Veteran stories collected during the normal course of providing spiritual care to combat-exposed Veterans and used by permission will provide insight into the theoretical concepts and interrelations of MP; proposed here as: circumstances in which moral obligations and/or ethical values come into conflict, forcing a choice between sides, none of which can be honored without violating the other. Acquainted with religious traditions that elucidate the perplexity and liberating effects of paradox, the work of Chaplains will also be recommended to address the problem of MP in wartime situations, highlighting the efficacy of acceptance-based spiritual interventions and therapeutic programs. Psychological and spiritual interventions that facilitate self-transcendence and non-dual awareness through experiential acceptance and a subscale measuring paradox-induced injury will be recommended for future research as well.

The Warrior's Journey Intervention: A Chaplain-Led Motivational, Preparatory Exercise for Enhancing Treatment Success.

Outcome literature has shown poor treatment engagement in efficacious, evidence-based post-traumatic stress disorder (PTSD) programs among returning veterans with combat-related psychological symptoms and calls for the development of motivational, preparatory exercises that circumvent stigma-related barriers and are delivered before or during the orientation phase of treatment. The psychological states of hope, meaning, and guilt have been found to impact motivation for treatment and the development and maintenance of post-trauma pathology and symptom severity. Given a chaplain's less stigmatized role, as compared to mental health providers, and proficiency in assessing these states and providing interventions that mediate change, often before a veteran is enrolled in a PTSD treatment program, this paper introduces a brief, chaplain-led, preparatory exercise called the "Warrior's Journey Intervention" (WJI). This narrative based, meaning-making exercise is designed to improve motivation for treatment and mitigate post-trauma symptoms by impacting hope, meaning, and guilt through use of a universally shared, metaphoric story of trauma recovery. A case study will demonstrate use of the intervention, observe its effects, and analyze mechanisms of change. Research is recommended at the end of the article to test the hypothesis that the intervention promotes motivation for treatment and reduces symptoms of PTSD and Moral Injury (MI). A standardized manual for the exercise is available from author.