“Trapped in their Shame”: A Qualitative Investigation of Moral Injury in Forensic Psychiatry Patients

Published date01 April 2022
Date01 April 2022
Subject MatterArticles
CRIMINAL JUSTICE AND BEHAVIOR, 2022, Vol. 49, No. 4, April 2022, 593 –612.
DOI: https://doi.org/10.1177/00938548211039877
Article reuse guidelines: sagepub.com/journals-permissions
© 2021 International Association for Correctional and Forensic Psychology
McMaster University
St. Joseph’s Healthcare Hamilton
St. Joseph’s Healthcare Hamilton
McMaster University
St. Joseph’s Healthcare Hamilton
McMaster University
St. Joseph’s Healthcare Hamilton
Homewood Research Institute
Western University
McMaster University
St. Joseph’s Healthcare Hamilton
McMaster University
St. Joseph’s Healthcare Hamilton
Homewood Research Institute
Individuals who engage in criminal behavior for which they are found not criminally responsible (NCR) may be at increased
vulnerability to experience moral pain and, in extreme circumstances, moral injury after regaining insight into the conse-
quences of their behavior. Yet, almost no research exists characterizing the nature, severity, or impact of moral pain in this
population. Semi-structured interviews were conducted with nine forensic psychiatric patients and 21 of their care providers.
Narratives were explored using thematic analysis. Findings demonstrate that NCR patients endorse symptoms consistent with
AUTHORS’ NOTE: First, we would like to sincerely thank the patients and staff members who volunteered to
share their experiences with us. In addition, we would like to thank the following individuals for their contribu-
tions to the project and manuscript development: Andrea Brown, Heather Millman, and David Streiner. This
study was supported in part by an award from the Forensic Psychiatry Program at St. Joseph’s Healthcare
Hamilton and by Canadian Institutes of Health Research (CIHR) grants to Margaret C. McKinnon and Ruth A.
Lanius. Margaret C. McKinnon is supported by the Homewood Chair in Mental Health and Trauma at
McMaster University. Ruth A. Lanius is supported by the Harris-Woodman Chair in Psyche and Soma at
Western University. Correspondence concerning this article should be addressed to Sophia L. Roth, Department
of Psychology, Neuroscience, & Behaviour, McMaster University, 1280 Main Street West, Hamilton, Ontario,
Canada L8S 4L8; e-mail: roths1@mcmaster.ca.
*Denotes co-senior authorship
1039877CJBXXX10.1177/00938548211039877Criminal Justice and BehaviorRoth et al. / Moral Injury in Forensic Psychiatry
moral injury, including feelings of guilt toward victims, shame for one’s behavior, and a loss of trust in one’s morality. Moral
pain is a strong driver of behavior and must be understood as part of a constellation of factors influencing criminality, risk,
and recovery. Future research must develop adequate tools to measure and characterize offense-related moral injury to under-
stand its impact on this population.
Keywords: moral injury; forensic; mental health; trauma; qualitative methods
Moral pain involving the experience of negative moral emotions like guilt, shame, and
anger provides immediate feedback as a consequence (or in anticipation) of our own behav-
ior or that of others and can influence future behavioral decision-making (Tangney et al.,
2007). When an individual behaves in a way that violates their moral code (committing
interpersonal violence, engaging in criminal behavior, cheating, stealing, etc.), moral pain
serves as punishment that deters reengaging in similar behavior in the future.
Mild experiences of moral pain are likely socially adaptive, discouraging immoral behav-
ior that may harm the social group (Haidt, 2003; Teper et al., 2015). More recently, how-
ever, researchers have become interested in examining the psychological impact of more
extreme and prolonged experiences of moral pain. Here, the term moral injury (MI) has
emerged to describe a syndrome characterized by psychological distress and impairment
following the perpetration or witnessing of morally violating behavior (Drescher et al.,
2011; Litz et al., 2009). To date, MI has been studied primarily in military members follow-
ing deployment (Hoffman et al., 2019) and has yet to be examined in contexts where the
moral violation is not legally justified, for example, after committing a criminal offense.
The current investigation qualitatively explored morally injurious symptomology in a sam-
ple of justice-involved individuals found not criminally responsible (NCR) on account of
mental disorder to determine the emotional experiences of these individuals following their
index offense.
Emerging from the military trauma literature, MI was first defined as an emotional, spiri-
tual, and psychological wound resulting from acts of commission or omissions that violate
one’s sense of morality and give rise to profound inner moral conflict (Drescher et al., 2011;
Litz et al., 2009). Initial measures of MI assessed for the experience of potentially morally
injurious events that fell under one of two categories: perpetration via commission or omis-
sion of morally violating acts (e.g., killing nonenemy combatants in the line of duty, failing
to save a life) or morally violating betrayals (e.g., receiving orders from superiors to stand
down and be complicit in the suffering of others). These early characterizations of MI were
phenomenological in nature and were criticized for their focus on population-specific expo-
sure to potentially morally injurious events rather than the experience of a moral wound
(Frankfurt & Frazier, 2016; Litz & Kerig, 2019; Yeterian et al., 2019).
More recently, work has been done to expand both the definition of MI and the popula-
tions in which it is studied. For example, syndromal definitions of MI have been put for-
ward in an effort to offer a clear and cohesive description that can be used to identify MI
symptomology regardless of the population being studied. One such perspective comes

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