Commentary on the Special Issue on Moral Injury: Leveraging Existing Constructs to Test the Heuristic Model of Moral Injury

Abstract

The literature on moral injury (MI) is currently undermined by the lack of clear boundaries regarding the construct and a dearth of research on the processes by which potentially morally injurious events lead to MI. The heuristic continuum model of moral stressors proposes ways of distinguishing between moral frustrations, moral distress, and MI. In this commentary, we highlight five testable principles that can be derived from the heuristic model and evaluated using well-established constructs. Specifically, we describe meaningful distinctions between guilt and shame and address how these moral emotions can be used to distinguish between moral distress and MI. We also describe the potential role of event-related rumination, shame proneness, and cognitive flexibility in the development of MI following exposure to potentially morally injurious events. We believe that these principles offer critical next steps for the advancement of the MI field and illustrate how MI research can be generalized beyond the military context.

Litz and Kerig (2019) introduced a heuristic continuum model of moral stressors that distinguishes between moral frustrations, moral distress, and moral injury (MI). The introduction of this model comes at a critical time as investigators are struggling to define and evaluate the boundaries of MI, which significantly undermines the MI literature and hinders future progress. With this conceptual advance, the next important question is: What well-established empirical constructs can be brought to bear to evaluate this theory? We agree with Litz and Kerig’s (2019) conceptualization that guilt and shame can help distinguish between moral distress and MI, and we believe it warrants further elaboration to develop testable principles to evaluate the heuristic model. Moreover, Griffin and colleagues’ (2019) review highlights the fact that little work has been done to evaluate the processes by which potentially morally injurious events (PMIEs) lead to MI. In this commentary, we aim to elaborate and extend the work by Litz and Kerig (2019) by outlining an empirical model and five testable principles, using well-validated constructs, with the hopes of promoting research that can be used to establish the boundaries and processes of MI.

Principle 2: Moral distress is characterized by shame-free guilt and self-blame with few negative beliefs about the self.

Although guilt and shame are often described together as important characteristics of MI, there are well-established differences between these emotions that allow us to empirically test the heuristic model. When transgressions occur, individuals often question their behavior during the event and whether they should have acted differently, resulting in guilt and associated self-blame. Guilt has adaptive qualities by promoting positive behavior change (Tangney, Stuewig, & Mashek, 2007). By contrast, shame involves an evaluation of oneself, resulting in negative beliefs about the self (e.g., “I am a monster”). Although guilt and shame often co-occur, shame-free guilt is likely to be adaptive, whereas shame, with or without guilt, is associated with negative outcomes, including social isolation, maladaptive coping, depression, and suicide (Tangney et al., 2007). If MI is marked by changes in one’s identity, as proposed by the heuristic model, it should be characterized by shame emotions and negative beliefs about the self, with or without guilt. In contrast, moral distress should be characterized by shame-free guilt and self-blame cognitions.

We believe that this distinction is also applicable to transgressions by others. Litz and Kerig (2019) suggest that individuals are likely to experience anger in response to events that involve others’ transgressions. However, it is important to not overlook feelings of shame that result from personalizing inactions, such as not intervening, preventing, or speaking up about an event. We propose that anger alone does not characterize MI. Instead, only when individuals personalize their inactions (e.g., “I am a horrible person for not intervening”) would transgressions by others result in MI.

Principle 3: Event-related rumination that primarily results in internal explanations is the process by which self-blame and guilt change into negative beliefs about the self and shame.

A key question concerns which processes move people from self-blame (“I did something wrong”) to assume global and stable negative beliefs about themselves (“I am a terrible person because of what I did”). When individuals recognize that they have been involved in wrongdoing, a natural reaction is to ruminate in an attempt to identify the perceived causal factors that led to the event (Kamijo & Yukawa, 2018; Watkins, 2008). This process can result in one of two conclusions: The individual identifies primarily external explanations for the event or the individual identifies primarily internal explanations for the event. If external explanations are found, then a person is likely to experience shame-free guilt. If mostly internal explanations are identified, a person will experience shame (Orth, Berking, & Burkhardt, 2006). Notably, this process of rumination may help to explain research findings that reactions to PMIEs are often delayed (Held et al., 2018). When individuals remain within the high-stakes situations in which PMIEs occur, there may not be the opportunity for rumination. However, when individuals are removed from the context, they may begin to ruminate on PMIEs, sparking the opportunity for the transition from guilt to shame.

Principle 4: Individuals with higher shame proneness are more likely to resolve event-related rumination with internal explanations compared to those with lower shame proneness.

A key factor that may affect whether rumination is resolved with external or internal explanations is shame proneness, a disposition to attribute transgressions to perceived characterological flaws. Shame proneness is associated with maladaptive responses, including depression and low self-esteem (Tangney et al., 2007). Individuals with high shame proneness are likely quicker to “resolve” any ongoing ruminative processes by finding internal explanations, whereas individuals with lower shame proneness are more likely to distinguish between their actions and identity (e.g., “Although I did something wrong, I am not a bad person”).

Principle 5: Individuals with higher cognitive flexibility are more likely to resolve event-related rumination with external explanations compared to those with lower cognitive flexibility.

Higher levels of cognitive flexibility can serve as a buffer from, and may even help to undo, maladaptive self-attributions. Cognitive flexibility is a process that enables individuals to entertain multiple explanations for their role in and the outcomes of events (Rende, 2000). Although individuals with high cognitive flexibility may experience guilt for their behavior, they would be more likely to identify context-specific rather than internal reasons for their behavior (e.g., “I did something horrible, but I was under stress and couldn’t see other options at that time”). In contrast, individuals with lower cognitive flexibility will adhere to more rigid rules (e.g., black-and-white thinking) and are more likely to be fixed on internal explanations.

Conclusion

Studying the boundaries of MI and the processes that lead to MI represent critical next steps for the advancement of the field. It is our hope that the five principles outlined in the present commentary can drive future research by creating a series of testable hypotheses. Moreover, these principles are generalizable beyond the military context, allowing this work to expand to new populations.