Table 1.
Characteristics of studies developing or using scales to assess moral injury (ordered by year of publication) (n = 22).
| Reference (abbreviation) | Design | Population Studied | Events vs. Symptoms | Moral Injury Dimension | No. Items (Rating) | Source Scale | Psychometrics |
|---|---|---|---|---|---|---|---|
| Henning and Frueh (30) (CGS) |
CS | 40 Veterans with PTSD | Symptoms only | Guilt | 15 (1 vs. 0) | Authors | α = .78 |
| Stein et al. (31) | CS | 122 ADM | Event Categories | MI by self MI by others |
2 (1 vs. 0) | Authors | kappa = .74-.90 |
| Gray et al. (32) | NRCT | 44 Marines | Cognitions and beliefs | Trauma-related cognitions | 33 (1-7) | Posttraumatic Cognitions Inventory | — |
| Nash et al. (12) | CS | 533 Marines 503 Marines |
Events and symptoms | Transgressions by self, others, and betrayal | 9 (1-6) | Authors | 2 factors (F) F1 α = .89 F2 α = .82 |
| Bryan et al. (27) | CS | 69 ADM | Symptoms only | Guilt | 6 (0-4) | Personal | α = .85 |
| Shame | 10 (0-4) | Feelings Questionnaire (PFQ-2) | α = .86 | ||||
| Ritov et al. (33) | CS | 147 ADM (Israeli) | Symptoms (moral response to events) | Moral objections | 4 (1-7) | Authors | α = .83 |
| Currier et al. (34) (MIQ-M) |
CS | 131 Veterans 82 Veterans | Events and symptoms | Betrayal, moral violations, guilt, others | 19 (1-4) | Authors | 1 factor α not reported |
| Bryan et al. (29) | CS | 474 ADM or Veterans | Symptoms only | Self-forgiveness | 6 (1-7) | Heartland Forgiveness Scale | α = .84 |
| Hijazi et al. (35) | CS | 167 Veterans | Symptoms only | Wrongdoing | 5 (0-4) | Trauma-Related Guilt Inventory (TRGI) subscale | α = .78 |
| Crocker et al. (36) | CS | 127 Veterans | Symptoms only | Shame | 24 (0-4) | Internalized Shame Scale; | α = .96 |
| Guilt | 32 (0-4) | TRGI | α = .87-.91 | ||||
| Campbell (37) (M-CoSS) |
CS | 378 Sailors 27 ADM |
Symptoms only | Maladaptive shame regulation | 6 by 4 | Author | α = .89 |
| Yan (38) | CS | 100 Veterans | Events only | Combat experiences (aftermath of battle) | 30 (1 vs. 0) | Deployment Risk & Resilience Inventory (DRRI) | α = .85-.86 |
| Dennis et al. (39) | CS | 603 Veterans | Events and symptoms | Atrocities committed Guilt (global) |
6 (1-5) 4 (0-4) |
Vietnam Stress Invent. TRGI subscale |
α = .87 α = .88 |
| Frankfurt et al. (40) | CS | 190 Veterans | Events and symptoms | Transgressive acts Feeling guilty |
8 (1 vs. 0) 1 (0-5) |
Clinician Administered PTSD Scale-IV |
K = .72 |
| Lancaster (41) | CS | 161 Veterans | Events and symptoms | Transgressions/betrayal Transgressive acts Shame and guilt |
6 (1-6) 7 (1 vs. 0) 10 (1-5) |
MIES (partial) Author State Shame and Guilt Scale |
— — α = .90 shame α = .88 guilt |
| Maguen et al. (42) | RCT | 33 Veterans with PTSD | Symptoms and beliefs | Maladaptive beliefs about killing | 55 (1-5) | Author (Killing Cognitions Scale) | — |
| Currier et al. (26) (EMIS-M) |
CS | 286 Veterans 624 Veterans |
Symptoms only | Self-directed, Other-directed (shame, guilt, betrayal, etc.) | 17 (1-5) | Authors | 2 factors α = .94-.95 (total) Test-retest α = .80 |
| Koenig et al. (23) (MISS-M-LF) |
CS | 214 Veterans 213 Veterans (with PTSD symptoms) | Symptoms only | Guilt, shame, moral concerns, betrayal, religious struggles, loss of faith, loss of meaning, loss of trust, difficulty forgiving, self-condemnation | 45 (1-10) | Items from multiple established scales, and study authors | 1-2 factors per subscale Overall α = .92 Test-retest α = .91 |
| Koenig et al. (24) (MISS-M-SF) |
CS | 214 Veterans 213 Veterans (as above) | Symptoms only | Same as above MISS-M-LF | 10 (1-10) | Based on MISS-M-LF | 1 item/scale Overall α = .73 Test-retest α = .87 |
| Nazarov et al. (43) (DEX) |
CS | 4854 ADM (Canadian) | Events only | Potential moral injury events (PMIEs) | 3 (1 vs. 0) | US/Canada Combat Experiences Scale | None reported |
| Bryan et al. (44) | CS | 930 ADM | Symptoms only | Anger outward, hostility inward, shame, guilt, sorrow; | 15 (1-5) | Differential Emotions Scale-IV | α = .85-.93 |
| low cohesion | 5 (1-5) | DRRI-2 | α = .91 | ||||
| Currier et al. (45) | CS | 1124 Veterans | Symptoms only | Religious/spiritual struggles | 22 (1-5) | Religious and Spiritual Struggles Scale | α = or >.90 |
CS, cross-sectional; ADM, Active Duty Military; α, Cronbach’s alpha (internal reliability).