Potentially Morally Injurious Events Research Articles

Properties of the modified self-forgiveness dual-process scale in populations at risk for moral injury.

Despite theory suggesting that self-forgiveness facilitates recovery from moral injury, no measure of self-forgiveness has been validated with individuals exposed to potentially morally injurious events (PMIEs). Military veterans, healthcare workers, and first responders who reported PMIE exposure (n=924) completed the Self-Forgiveness Dual-Process Scale, which assesses two dimensions of the self-forgiveness process. The first dimension, value affirmation, refers to appraising personal responsibility and being willing to make amends for one's involvement in a PMIE. The second dimension, esteem restoration, refers to accepting oneself as valuable and capable of growth despite one's failures and imperfections. Exploratory and Confirmatory Factor Analyses replicated the original scale's two-factor structure in 10 items modified to apply to the diverse contexts in which PMIEs occur. Next, we found that the factor structure, item loadings, and item intercepts were fully or partially invariant across professions, genders, races, ages, and religious affiliations in a series of Multi-Group Confirmatory Factor Analyses. Finally, diverging patterns of associations between value affirmation and esteem restoration with moral distress, posttraumatic stress, depression, insomnia, functional impairment, and posttraumatic growth provide evidence of convergent and discriminant validity between the subscales. The modified self-forgiveness dual process scale is the first measure of self-forgiveness to be validated with individuals exposed to a PMIE. Researchers and clinicians can use the scale to examine how self-forgiveness (or difficulties with forgiving oneself) relates to moral injury.

Exploring heterogeneity in PTSD symptoms and associated predictors and outcomes in Afghanistan veterans: A latent profile analysis

ABSTRACT Research on posttraumatic stress symptoms (PTSS) typically focuses on diagnosis or symptom severity, however, this overlooks the variety of symptom patterns that exist. Latent profile analysis was used to explore PTSS profiles in a sample of Norwegian Afghanistan veterans (n = 4052, 91.7% males). Multinomial logistic regression analyses were conducted to examine predictors and outcomes associated with PTSS profile membership. Three profiles emerged: Low Symptoms profile (85%); High Numbing and Arousal profile (13%); and High Symptoms profile (2%). Being female, lower number of deployments, barriers to disclose war-related experiences, and higher number of potentially morally injurious events (PMIEs) were associated with belonging to the High Symptoms profile compared to the High Numbing and Arousal (Male gender: OR = 0.37, p < .05; Number of deployments: OR = 0.68, p < .05; Barriers to disclose: OR = 1.39, p < .001; PMIEs: OR = 1.15. p < .05), or Low Symptoms profile (Male gender: OR = 0.36, p < .05; Number of deployments: OR = 0.67, p < .01; Barriers to disclose: OR = 1.80, p < .001; PMIEs: OR = 1.32. p < .001). Participants in the High Symptoms profile had the highest probability of mental health service use (0.37) and endorsing suicidal ideation (0.38), compared to the two other profiles (p < .01). Participants in the High Numbing and Arousal profile had a higher probability of seeking professional mental health care (0.17), endorsing suicidal ideation (0.16), and reporting more suicide attempts compared to the Low Symptom profile (0.02 vs. 0.00, p < .001). These findings highlight the importance of considering the heterogeneity of PTSS profiles and understanding the predictors and responses of individuals who exhibit elevated PTSS symptoms.

Understanding psychological outcomes following exposure to potentially morally injurious events in animal care: development of the Moral Distress-Posttraumatic Growth Scale for Veterinary Professionals

ABSTRACT Aims To generate a taxonomy of potentially morally injurious events (PMIE) encountered in veterinary care and develop an instrument to measure moral distress and posttraumatic growth following exposure to PMIE in the veterinary population. Methods Development and preliminary evaluation of the Moral Distress-Posttraumatic Growth Scale for Veterinary Professionals (MD-PTG-VP) employed data from veterinary professionals (veterinarians, veterinary nurses, veterinary technicians) from Australia and New Zealand across three phases: (1) item generation, (2) content validation, and (3) construct validation. In Phase 1 respondents (n = 46) were asked whether they had experienced any of six PMIE and to identify any PMIE not listed that they had experienced. In Phase 2 a different group of respondents (n = 11) assessed a list of 10 PMIE for relevance, clarity and appropriateness. In Phase 3 the final instrument was tested with a third group of respondents (n = 104) who also completed the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT), a measure of posttraumatic stress, and the Stress-Related Growth Scale–Short Form (SRGS-SF) a measure of perceived posttraumatic growth. Spearman’s correlation coefficients were calculated between respondent scores on each of the MD-PTG-VP subscales, the SPRINT, and the SRGS-SF to assess construct validity. Results A 10-item taxonomy of PMIE encountered in veterinary care was generated in Phase 1. Items were deemed relevant, clear and appropriate by veterinary professionals in Phase 2. These were included in the developed instrument which measures frequency and impact of exposure to 10 PMIE, yielding three subscale scores (exposure frequency, moral distress, and posttraumatic growth). Assessment of construct validity by measuring correlation with SPRINT and SRGS-SF indicated satisfactory validity. Conclusions The MD-PTG-VP provides an informative tool that can be employed to examine professionals’ mental health and wellbeing following exposure to PMIE frequently encountered in animal care. Further evaluation is required to ascertain population norms and confirm score cut-offs that reflect clinical presentation. Clinical relevance Once fully validated this instrument may be useful to quantify the frequency and intensity of positive and negative aspects of PMIE exposure on veterinary professionals so that accurate population comparisons can be made and changes measured over time.

How do you see me? The impact of perceived societal recognition on PTSD symptoms amongst Norwegian peacekeepers

ABSTRACT Background: The peacekeeper role is different to that of traditional combat, however, peacekeepers, like combat soldiers, may also be exposed to high levels of dangerous and/or potentially morally injurious events (PMIEs). Objective: It was hypothesized that given the centrality of societal approval for the peacekeeping mission, in addition to the known relevance of perceived social support, perceived societal recognition would influence PTSD symptoms (PTSS) and depression. It was hypothesized that perceived societal recognition would moderate the effect of exposure to potentially traumatic events and PMIEs on psychological outcomes. Method: 8341, predominantly male, former UNIFIL peacekeepers, almost three decades following deployment, answered a survey to determine the impact of perceived social support and perceived societal recognition, on PTSS and depression symptoms. Hierarchical regression analyses were performed for PTSS and depression separately and moderation analysis was performed for perceived societal recognition. Results: Exposure to potentially traumatic events showed the greatest predictive value for PTSS and exposure to PMIEs and potentially traumatic events were equally predictive of depression symptoms. While perceived social support presented the strongest buffer for PTSS and depression symptoms following UNIFIL deployment, perceived societal recognition also significantly contributed to the prediction of both PTSS and depression symptoms. There was a weak moderation effect of perceived societal recognition on trauma type in the development of PTSS. Conclusions: Even decades following peacekeeping deployment, military experiences have a significant impact on psychological functioning. This impact is both from the types of events experienced and from the perception of social and societal support upon return home.

The differential and accumulative impacts of self and other sources of moral injury on well-being in mental healthcare staff

PurposeResearch has established the prevalence and relevance of moral injury in healthcare workers, though less attention has been paid to the different classes of potentially morally injurious events (PMIEs) experienced by this population and their impact. This exploratory study sought to examine the frequency of self- and other-generated PMIE classes and their associations with demographic characteristics and well-being outcomes among mental healthcare staff.Design/methodology/approachSecondary analysis of data drawn from two cross-sectional surveys of 267 frontline and leadership staff from mental healthcare settings in the UK was conducted. Responses on the Moral Injury Events Scale and the Short Professional Quality of Life Scale were extracted for analysis.FindingsBetrayal by others was most frequently endorsed (61.8%), whilst self-transgressions were least frequently reported (25.5%). After controlling for the number of PMIE classes experienced, betrayal significantly predicted secondary traumatic stress (p = 0.01) and burnout (p = 0.04). Additionally, other transgressions significantly predicted secondary traumatic stress (p = 0.008). The predictive effects of self-transgressions on burnout, secondary traumatic stress and compassion satisfaction were all nonsignificant after controlling for the number of PMIE classes experienced.Practical implicationsFindings highlight differences in the frequency and impact of self and other PMIEs experienced by healthcare professionals. Reducing cumulative exposure to differential PMIE classes appears to be of critical importance to improving occupational well-being in this group.Originality/valueTo our knowledge, this study is the first to explore the associations between PMIE classes and occupational well-being in a mental healthcare population, inclusive of frontline and leadership staff.

Using the Moral Injury and Distress Scale to identify clinically meaningful moral injury.

Despite the proliferation of moral injury studies, a remaining gap is distinguishing moral injury from normative distress following exposure to potentially morally injurious events (PMIEs). Our goal was to leverage mental health and functional measures to identify clinically meaningful and functionally impairing moral injury using the Moral Injury and Distress Scale (MIDS). Participants who endorsed PMIE exposure (N = 645) were drawn from a population-based sample of military veterans, health care workers, and first responders. Using signal detection methods, we identified the optimally efficient MIDS score for detecting clinically significant posttraumatic stress and depressive symptom severity, trauma-related guilt, and functional impairment. The most efficient cut scores across outcomes converged between 24 and 27. We recommend a cut score of 27 given that roughly 70% of participants who screened positive on the MIDS at this threshold reported clinically significant mental health symptoms, and approximately 50% reported severe trauma-related guilt and/or functional impairment. Overall, 10.2% of respondents exposed to a PMIE screened positive for moral injury at this threshold, particularly those who identified as a member of a minoritized racial or ethnic group (17.9%) relative to those who identified as White, non-Hispanic (8.0%), aOR = 2.52, 95% CI [1.45, 4.42]. This is the first known study to establish a cut score indicative of clinically meaningful and impairing moral injury. Such scores may enhance clinicians' abilities to conduct measurement-based moral injury care by enabling them to identify individuals at risk of negative outcomes and better understand risk and protective factors for moral injury.

Dispositional mindfulness moderates the links between potentially morally injurious event exposure and symptoms of anxiety and depression but not suicidal ideation.

Exposure to potentially morally injurious events (PMIEs) is a pervasive threat for military service members and may be associated with symptoms of anxiety, depression, and suicidal ideation. However, coping mechanisms, such as mindfulness, may ameliorate symptoms and improve recovery. Two studies were conducted to test dispositional mindfulness as a moderator of the links between PMIEs, as assessed using the Moral Injury Events Scale (i.e., total score and Self-Transgression, Other-Transgression, and Betrayal subscale scores), and symptoms of anxiety, depression, and suicidal ideation among different samples of active-duty soldiers in garrison. In Sample 1 (N = 310), mindfulness buffered the links between PMIE exposure and symptoms of both anxiety, ∆R2 =.02, and depression, ∆R2 =.03. In Sample 2 (N = 669), mindfulness moderated the link between the MIES Betrayal subscale and anxiety symptoms, ∆R2 =.01. The results suggest that dispositional mindfulness may be a protective factor against some of the negative impacts of PMIE exposure. Further implications are discussed.

The impact of moral injury on trajectories of depression: a five-year longitudinal study among recently discharged Israeli veterans

ABSTRACT Background Perpetrating or witnessing acts that violate one's moral code are frequent among military personnel and active combatants. These events, termed potentially morally injurious events (PMIEs), were found to be associated with an increased risk of depression, in cross-sectional studies. However, the longitudinal contribution of PMIEs to depression among combatants remains unclear. Method Participants were 374 active-duty combatants who participated in a longitudinal study with four measurement points: T1-one year before enlistment, T2-at discharge from army service, and then again 6- and 12-months following discharge (T3 and T4, respectively). At T1, personal characteristics assessed through semi-structured interviews. At T2-T4, PMIEs and depressive symptoms were assessed. Results At discharge (T2), a total of 48.7% of combatants reported experiencing PMIEs incident, compared with 42.4% at T3 and 30.7% at T4. We found a significant interaction effect in which combatants endorsing PMIEs at discharge reported higher severity of depression symptoms at discharge (T2) than combatants who reported no PMIEs. This effect decreased over time as depression levels were lower at T3 and T4. Conclusions PMIE experiences, and especially PMIE-Betrayal experiences, were found to be valid predictors of higher severity of depression symptoms after the first year following discharge.

Health and psychiatric impairment associated with moral injury, military sexual trauma, and their co-occurrence in U.S. combat veterans

BackgroundMilitary sexual trauma (MST) and moral injury (MI) are associated with adverse psychiatric and health outcomes among military veterans. However, no known population-based studies have examined the incremental burden associated with the co-occurrence of these experiences relative to either alone. MethodCross-sectional data were analyzed from the National Health and Resilience in Veterans Study, a nationally representative sample of 1330 U.S. combat veterans. Veterans reported on history of exposure to MST and potentially morally injurious events (PMIEs). Analyses estimated the lifetime prevalence of MST only, PMIEs only, and co-occurring MST and PMIEs; and examined associations between MST/PMIEs status and psychiatric and physical health comorbidities, functioning, and suicidality. ResultsThe lifetime weighted prevalence of exposure to MST only, PMIEs only, and co-occurring MST and PMIEs were 2.7%, 32.3%, and 4.5%, respectively. Compared with all other groups, the co-occurring MST + PMIEs group reported greater severity of posttraumatic stress, depression, generalized anxiety, and insomnia symptoms. They also scored lower on measures of physical, mental, and psychosocial functioning, and reported a greater number of chronic medical conditions and somatic complaints. Veterans with co-occurring MST + PMIEs were more than twice as likely as those with MST only to report past-year suicidal ideation. ConclusionsThe co-occurrence of MST and MI is associated with a greater psychiatric and health burden among combat veterans than either experience alone. Results underscore the importance of assessing and treating MST and MI in this population. Findings underscore the importance for future work to parse overlap between morally salient aspects of MST and the concept of moral injury.

Potentially morally injurious events as a mediator of the association of gratitude and mindfulness with distress.

Potentially morally injurious events (PMIEs) are events that contradict one's own personal ethics and may promote a deep sense of violation, leading to psychological distress. Individuals with greater trait gratitude and mindfulness may be less likely to perceive events as being morally injurious and may, in turn, be less likely to experience subsequent distress. The current study seeks to examine (a) PMIE rates in a multioccupational first responder sample and (b) the indirect effect of trait gratitude and mindfulness on psychological distress via fewer perceived PMIEs. 293 first responders from agencies/departments within southeastern Texas (in-person) and nationwide (online) completed a survey assessing PMIEs, PTSD symptoms (PCL-C), anxiety (GAD-7), depression (PHQ-8), gratitude (GRAT-S), and mindfulness (MAAS). PMIEs were common (61% witnessed a transgression; 21% committed a transgression; 40% felt betrayed by others). Gratitude was indirectly associated with fewer PTSD [-.09, 95% CI (-.13, -.05)], anxiety [-.03, 95% CI (-.04, -.01)], and depression [-.03, 95% CI (-.05, -.01)] symptoms via lower PMIEs. Similarly, mindfulness was indirectly associated with fewer PTSD [-.92, 95% CI (-1.55, -.38)], anxiety [-.20, 95% CI (-.42, .02)], and depression [-.26, 95% CI (-.48, -.06)] symptoms via lower PMIEs. PMIEs were common in this first responder sample and associated with increased distress. Trait gratitude and mindfulness may protect first responders from perceiving events as morally injurious, which may lead to improved mental health. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Moral Injury and Distress Scale: Psychometric evaluation and initial validation in three high-risk populations.

The concept of moral injury resonates with impacted populations, but research has been limited by existing measures, which have primarily focused on war veterans and asked about exposure to potentially morally injurious events (PMIEs) rather than PMIE exposure outcomes. Our goal was to develop and examine the psychometric properties of the Moral Injury and Distress Scale (MIDS), a new measure of the possible emotional, cognitive, behavioral, social, and/or spiritual sequelae of PMIE exposure. The MIDS was validated by surveying three groups: military veterans, healthcare workers, and first responders (N = 1,232). Most respondents (75.0%; n = 924) reported PMIE exposure. Analyses yielded 18 items that contributed to a single latent factor representing moral distress with fully or partially invariant configurations, loadings, and intercepts across occupational groups. The MIDS full-scale score demonstrated excellent internal consistency (α = .95) and moderate 2-week stability (r = .68, p < .001, n = 155). For convergent validity, associations between the MIDS and PMIE exposure measures, as well as putative indicators of moral injury (e.g., guilt, shame), were positive and large (r = .59-.69, p < .001), as were correlations with posttraumatic stress, depressive, and insomnia symptoms (r = .51-.67, p < .001). The MIDS was a stronger predictor of functioning than PMIE exposure measures, explaining seven times greater unique variance (9% vs. 1%-1.3%). The MIDS is the first scale to assess moral injury symptoms indexed to a specific PMIE that is validated across several high-risk populations. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The impact of moral injury on suicide risk among recently discharged Israeli veterans: A longitudinal moderated mediation model of trauma-related guilt and self-forgiveness.

Exposure to potentially morally injurious events (PMIEs) during military service has been associated with heightened trauma-related guilt levels, which in turn, could increase suicide risk among combat veterans. However, no longitudinal study has established temporal associations between these variables while examining a Moderated mediation model with self-forgiveness as a possible moderator of the PMIEs-suicide risk links during the first year following discharge. Participants were 374 active-duty Israeli combatants who participated in a 5-year longitudinal study with three measurement points: 1 month before discharge from army service (T1), then 6 months (T2), and 12 months (T3) following their discharge. Data were assessed through semistructured interviews and validated self-report questionnaires. All PMIE dimensions at T1 were negatively associated with self-forgiveness at T1 and positively associated with levels of trauma-related guilt at T2 and suicide risk at T3. Our longitudinal moderated mediation model findings indicate that, among those reporting low levels of self-forgiveness, higher levels of PMIE-Self and PMIE-Others at T1 contribute to trauma-related guilt levels at T2, which, in turn, are linked to a higher suicide risk at T3 among those reporting low levels of self-forgiveness. Experiencing PMIEs, especially PMIE-Self and PMIE-Other, proved to be validated predictors of trauma-related guilt and, in turn, of suicide risk during the first year after the veterans' discharge. Combatants at their discharge from the military should have access to targeted self-forgiveness interventions, as these interventions can have a buffering effect on the development of suicidal ideation and behaviors following PMIEs. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Longitudinal associations between exposure to potentially morally injurious events and suicidal ideation among recently discharged veterans – The mediating roles of depression and loneliness

BackgroundExposure to potentially morally injurious events (PMIEs) during military service is associated with heightened suicidal ideation (SI). However, no longitudinal study has established temporal associations between these variables and examined the possible mediating roles of depression and loneliness in this effect. MethodsParticipants were 374 active-duty Israeli combatants who participated in a five-year longitudinal study with four measurement points: T1- one year before enlistment, T2- one month before discharge from army service, and then again six months and twelve months following their discharge (T3 and T4, respectively). Data were assessed through semi-structured interviews and validated self-report questionnaires. ResultsAbove and beyond pre-enlistment personal characteristics (T1) and combat exposure (T2), PMIEs-‘betrayal’ (T2) predicted more frequent SI over the past twelve months (T4) through the mediation of depression. Moreover, both PMIEs-‘betrayal’ and ‘self’ (T2) predicted more frequent SI over the past twelve months (T4) through the mediation of loneliness. LimitationsWe used self-report measures to assess PMIEs and SI, which may suffer from various biases. ConclusionsOur findings are the first to provide evidence of longitudinal, temporal associations between exposure to PMIEs and SI. Notably, potential interventions might consider addressing the loneliness experienced following exposure to PMIEs during military service, among recently discharged traumatized veterans.

Moral injury and its mental health consequences among protesters: findings from Israel’s civil protest against the government's judicial reform

ABSTRACT Background: Government actions and participating in protracted-duration protests against it affect protesters' mental health, leading to high distress levels, such as posttraumatic and depressive symptoms. Aside from exposure to violence and other issues, protest participation can pose unique challenges to the protesters as they may be exposed to potentially morally injurious events (PMIEs), such as the betrayal of leaders they once trusted. This study's primary objective was to examine the extent of psychological difficulties among civilians participating in long-duration protests in Israel. More specifically, the study aimed to understand the contribution of exposure to protest-related PMIEs to psychological difficulties such as posttraumatic and depressive symptoms. Method: Participants comprised 4036 Israelis who were actively involved in the unfolding civil protest movement against the government-led judicial overhaul between January 2023 and August 2023. The protesters completed validated self-report questionnaires that included measures of PMIE exposure, PTSD and depressive symptoms. Results: About half (44.3%) of the sample met the criteria for self-report diagnosis of major depression and 10.6% for PTSD. Most of the protesters indicated their exposure to at least one moral injury event, with 63.9% reporting exposure to PMIE-Betrayal. Protesters exposed to PMIEs reported significantly higher levels of both PTSD and depression than non-PMIE-exposed protesters. Hierarchical regression analyses revealed that, beyond demographics and protest-related characteristics such as exposure to violence, PMIE dimensions significantly contributed to both PTSD and depression levels. Conclusions: The findings highlight the mental burden of protesters during the civil protests against the judicial overhaul in Israel. More central to the present research, the findings highlight the critical contribution of PMIEs exposure to this burden. Clinicians treating protesters coping with depression and PTSD following the civil actions should attend to their exposure to PMIEs, which may relate to the deleterious psychological effects among protesters.

The contribution of childhood adversity and potentially traumatic events during military service to PTSD and complex PTSD symptoms among Israeli women veterans.

Adverse childhood experiences (ACEs) and exposure to potentially traumatic events (PTEs) during military service are associated with mental health problems. However, knowledge about relative contributions of these factors to non-U.S. women combat veterans' posttraumatic sequelae is sparse. This study examines associations between ACEs, combat exposure (CES), military sexual trauma (MST), potentially morally injurious events (PMIEs), posttraumatic stress disorder (PTSD), and complex PTSD (CPTSD) symptoms among women veterans. A volunteer sample of Israeli women combat veterans (n = 885) and noncombat veterans (n = 728) responded to self-report questionnaires in a cross-sectional design study. Combat veterans reported higher total average ACEs and were more likely to experience three or more ACEs and specific ACEs of physical abuse and emotional neglect, as compared to noncombat veterans. Combat veterans also reported higher levels of CES, PMIEs, higher prevalence of MST, and higher levels of PTSD symptoms, but not CPTSD symptoms, as compared to noncombat veterans. Importantly, ACEs, CES, MST-assault, and PMIEs of betrayal predicted PTSD symptoms, while only ACEs and PMIEs of betrayal predicted CPTSD symptoms. This study emphasized the relatively high exposure to PTEs and PTSD symptoms of women combat veterans as compared to noncombat veterans. Our findings also confirm prior studies demonstrating associations between ACEs, CES, MST, and mental health problems. Importantly, we demonstrated the unique contribution of betrayal-based PMIEs and the differential associations of PTEs with PTSD and CPTSD symptoms among combat veterans. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Moral Injury as a Transdiagnostic Risk Factor for Mental Health Problems in Detained Youth

Youth who become involved in the juvenile justice system are at highly elevated risk for many emotional and behavioral problems. Past research has often focused on trauma exposure as a transdiagnostic risk factor in this population. However, distress resulting from perpetrating or witnessing acts that conflict with one’s deeply held moral beliefs, termed moral injury, may also play a role in predisposing these youth toward negative mental health outcomes. This study utilized a sample of 96 youth housed in secure detention centers and tested associations between exposure to potentially morally injurious events (PMIEs) and mental health outcomes, including anxiety, depression, posttraumatic stress, and nonsuicidal self-injury (NSSI). After controlling for trauma exposure and demographic variables, PMIEs were significantly and positively associated with symptoms of depression and anxiety, as well as engagement in NSSI. Implications for research and clinical practice are discussed.

Prospective associations between psychological factors, potentially morally injurious events, and psychiatric symptoms among Israeli combatants: The roles of ethical leadership and ethical preparation.

Exposure to potentially morally injurious events (PMIEs) during military service is known to be associated with psychiatric symptoms. However, antecedents and outcomes of exposure to PMIEs have only been studied in cross-sectional or retrospective-designed studies. In this prospective study, we examined associations between preenlistment characteristics, predeployment psychological factors, exposure to PMIEs, posttraumatic stress disorder (PTSD), and psychiatric symptoms, and the moderating roles of ethical leadership and ethical preparation, among combatants. A sample of 335 active-duty Israeli combatants participated in a 2.5-year prospective study with three waves of measurements. Participants' characteristics were assessed via semistructured interviews and validated self-report measures between 2019 and 2021. Above and beyond preenlistment personal characteristics and psychiatric symptoms, predeployment psychological flexibility predicted higher levels of exposure to PMIEs-Other and Betrayal, and combat exposure predicted higher levels of exposure to PMIEs-Self, Other, and betrayal. Moreover, PMIEs-Betrayal predicted higher levels of PTSD and psychiatric symptoms, and ethical preparation predicted lower PTSD and psychiatric symptoms. Importantly, among combatants who reported high levels of ethical preparation and leadership, the association between exposure to PMIEs and PTSD and psychiatric symptoms following deployment dissolved. This is the first prospective study of antecedents and outcomes of exposure to PMIEs among active-duty combatants. Clinicians treating combatants should be aware of the putative role of psychological flexibility for exposure to PMIEs, as well as the promising mitigating role of ethical leadership and preparation for moral injury and psychopathological outcomes among combatants. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Perceptions of Military Experience Among Veterans Reporting Lifetime Warzone Moral Injury.

Exposures to potentially morally injurious events (PMIEs) and possible moral injury are risk factors for a range of difficulties impacting individual functioning. Although exposure to PMIEs is a somewhat common product of war, qualitative methods to understand Veterans' experiences of moral injury and Veterans Affairs treatment are limited. To better characterize Veterans' experiences, 14 male warzone Veterans who reported moral injury post-warzone deployment and completed posttraumatic stress disorder treatment in the past year were asked to describe their military service as part of a qualitative study. Through thematic analysis, we found two moral injury-consistent themes and four subthemes. The first theme was "military experiences were associated with morally questioning one's self" with subthemes of "moral shift" and "depersonalization." The second theme was "military experiences were associated with morally questioning others" with subthemes of "disillusionment" and "resignation." Based on these findings, we conclude with a discussion of treatment implications for moral injury.

When healers get wounded! Moral injury in healthcare providers during the COVID-19 pandemic in Pakistan.

Moral injury (MI) is a multi-faceted and multidimensional phenomenon. Occupational MI has been studied mainly among military personnel and first responders and is linked to mental health problems. MI encompasses negative moral emotions such as shame, guilt, and anger leading to distress, and impairment in social and occupational functioning. The COVID-19 pandemic predisposed healthcare providers to moral dilemmas, potentially morally injurious events (PMIEs), and MI. We aimed to assess the prevalence and predictors of MI in healthcare providers during the COVID-19 pandemic in Pakistan. This cross-sectional study was conducted in July-October 2021 among physician/clinician staff working at teaching hospitals in Lahore. The Moral Injury Symptoms Scale-Health Professionals (MISS-HP) was used to collect data. SPSS 26 was used for data analysis applying Wilcoxon Mann-Whitney U and Kruskal-Wallis tests on non-normally distributed data at α = 0.05. Predictors of MI were ascertained through Binary Logistic Regression analysis. Four hundred and twenty physicians responded to the questionnaires. The Median (IQR) MI scores were 37(28-47). Guilt, moral concerns, and shame were higher-scoring MI dimensions. 40.8% (n = 171) suffered from clinically significant distress and impaired functioning while 14.3% (n = 60) from severe distress. Gender, department, and history of psychiatric illness predicted higher levels of distress which were 1.9 times higher in females than males and 2.5 times higher with a history of psychiatric illness. Working on the front lines did not predict MI. Our findings highlight the substantial burden of MI in our sample during COVID-19, having implications for healthcare providers' well-being, healthcare quality, and service delivery. This calls for concerted efforts from all stakeholders to better prepare for future disasters through effective human-resource policies, pre-trauma exposure soft-skills training, effective teamwork and communication strategies; self-stewardship and resilience modules, and mental health support for healthcare providers. The dimensional construct of MI may vary across cultures; hence we recommend further cross-cultural research on MI in healthcare providers, particularly in the context of public health disasters.

Factors associated with exposure to potentially morally injurious events (PMIEs) and moral injury in a clinical sample of veterans

IntroductionMoral injury is not inevitable following exposure to a potentially morally injurious event (PMIE). Since moral injury is associated with poor mental health outcomes, it is clinically important to understand when moral injury develops following PMIE exposure and when it does not. The current study explores associations between both PMIE exposure and moral injury with a range of mental health and functioning outcomes to explore possible differences in comorbidities between those who do, and those who do not go on to develop moral injury following PMIE exposure. MethodsA total of 428 treatment-seeking veterans from a national charity (Mage = 50.4, SDage = 10.9) completed an online questionnaire which included the Moral Injury Outcome Scale to assess PMIE exposure and moral injury symptoms, and measures of other mental health outcomes. ResultsIndependent t-tests revealed significant differences between mean scores on measures of common mental health difficulties (CMD, anxiety and depression), physical health problems, loneliness and complex PTSD between veterans who had experienced a PMIE and veterans who had not. The presence of caseness for CMD, physical health difficulties, anger difficulties, PTSD and CPTSD were significantly associated with moral injury, and trust and shame subscales of the MIOS. DiscussionThese findings build on previous theory and research indicating a distinction between exposure to PMIEs and moral injury. These distinctions suggest potential risk factors for developing moral injury following a PMIE and highlight the possible relevance of poor psychosocial functioning in the development of moral injury. Longitudinal research is needed to explore the observed associations further.