Moral Injury: A Systematic Review of Trauma Treatment Factors

Guilt, shame, and anger are widely recognized as core emotional features of moral injury. In the absence of a validated treatment for moral injury, understanding how patients respond to existing interventions is key. This systematic review assessed the impact of trauma treatments measuring guilt, shame and anger, on patient wellbeing outcomes and assessed the impact of demographic characteristics on guilt, shame and anger outcomes. This study followed the PROSPERO (the International Prospective Register of Systematic Reviews) protocol and is in adherence with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In order to be included in the review, studies must have delivered trauma treatment in an adult sample, and included validated measures of guilt, shame, anger, moral injury and patient wellbeing factors (such as measures of social support or health). An initial database search identified 5,053 studies, de-duplication, title and abstract review and full-text reviews were completed, leading to twenty-five studies included in final review. This review found that patient wellbeing factors were often not addressed in treatments. No single treatment consistently emerged as a universally beneficial approach. This review highlights the need in clinical treatment and research development to more frequently measure and support patient wellbeing factors holistically in trauma treatment.