Assessing Moral Injury and its Clinical Associations in a UK Secure Care Population

Introduction: Moral Injury (MI) represents a type of trauma that can manifest after committing or witnessing transgressions which result in feelings of shame, guilt, and inner turmoil. Although originally conceived and researched in military settings, emerging research has focused on broader populations including health professionals, social workers, police, and prison staff. Few empirical studies have focused on service-user populations, especially those in forensic clinical settings despite the risk factors associated with these groups.

Method: This cross-sectional study assessed the presence of MI along with its clinical associations among a UK forensic secure care sample (n=38). It used a series of brief psychometric tools including a modified Moral Injury Event Scale (MIES), International Trauma Questionnaire (ITQ), Recovering Quality of Life (ReQoL-20), State Shame and Guilt Scale (SSGS), and Self-Compassion Scale-Short Form (SCS-SF).

Results: MI was endorsed by most participants (89.5%) with an overall moderate-to-high level rating (M=38.2). Other-transgressions (M=9.2) and betrayal (M=13.6) were relatively higher compared with self-transgressions (M=15.4) based on possible maximum sub-domain scores. The overall MI scores were associated with ratings of trauma (r=.550), guilt (r=.470), and poorer quality-of-life (r=-.341), though not shame or self-compassion (p>.05). Regression analyses revealed a moderate contribution of ITQ scores in MIES score variability.

Discussion: MI scores were similar to or higher than other populations from across the literature demonstrating a high presence of potentially morally injurious events and related distress among the sample. The findings support the need for trauma-based assessments of moral emotional experiences within a forensic secure care context.