The Moral Injury Symptom Scale — Military Version

Harold G. Koenig's 2018 paper in the Journal of Religion and Health is the validation study for the Moral Injury Symptom Scale — Military Version (MISS-M), the second major psychometrically validated instrument for the construct after Currier's MIQ-M. Koenig is Professor of Psychiatry at Duke University Medical Center and director of Duke's Center for Spirituality, Theology and Health; the co-author list (Donna Ames, Nagy A. Youssef, John P. Oliver, Fred Volk, Ellen J. Teng, and others) spans VA Medical Centers in Augusta, Los Angeles, Durham, Houston, and San Antonio, plus Liberty University in Lynchburg.

The methodology was a multi-site VA / DoD study of 427 veterans and active-duty service members with PTSD symptoms; the candidate items were reduced through factor analysis and tested against existing measures of guilt, shame, religiosity, and PTSD. The final 45-item scale has ten subscales and strong overall reliability (Cronbach's α = .92 for the total scale; .56–.91 for individual subscales) and good test-retest properties (.91 for the total scale).

The substantive distinction from Currier's MIQ-M is the explicit inclusion of religious-struggle subscales — religious struggles, loss of religious faith/hope, difficulty forgiving — alongside the standard guilt, shame, moral concerns, meaning-loss, trust, and self-condemnation subscales. The design choice reflects Koenig's long-standing research-programme commitment to the religion-and-mental-health subfield. Critics inside the measurement subfield have flagged this as theory-laden measurement: a scale designed by a researcher with strong priors about religion's role in mental health will, predictably, produce results in which religious content correlates with the construct of interest. Sympathetic readers respond that the patient population's own use of religious vocabulary in describing their condition justifies the inclusion, and that stripping the religious content out of the measurement frame is itself a theoretical commitment, not a neutral methodological choice.

The Journal of Religion and Health is a Springer peer-reviewed journal with an editorial focus on the intersection of clinical mental health and religious / spiritual content. Publishing the MISS-M validation there rather than in a flagship clinical- psychology journal is itself a signal of the scale's intended research community; the MIQ-M sits in Clinical Psychology and Psychotherapy and the MISS-M sits in Religion and Health, and that placement difference is doing some of the field-mapping work the secondary literature has discussed.

The stake is research-programmatic and substantively religious. Koenig is openly invested in the claim that religious practice and content are mental-health-relevant in ways that mainstream psychiatry has under-engaged with; the MISS-M is the moral-injury-specific operationalisation of that research programme. The instrument has had wide adoption in the chaplaincy-research and Christian-mental-health literatures, and increasing adoption inside VA chaplaincy services; it is less common in the secular-clinical literature than the MIQ-M.

For the moral-injury corpus this paper is the second principal measurement paper alongside Currier (2015). The two instruments are built on different implicit definitions of the construct — the MIQ-M is more purely Litz-style PMIE-based, the MISS-M is more theologically inflected — and choosing between them in research design is itself a substantive choice about what moral injury is. The 2022 short-form validation of the MISS-M (MISS-M-SF) is the place to read for the more recent operationalisation.