Moral Injury and Its Consequences Among Combat Veterans: Preliminary Findings on the Role of Moral Judgment.

Exposure to potentially morally injurious events (PMIEs) among combat veterans has been acknowledged as a significant stressful combat event that may lead to various mental health problems, including depression and moral injury (MI), outcomes of shame and guilt. Recent studies have examined both risk and protective factors that can contribute to PMIEs and their consequences. However, while the general level of one's moral judgment is a logical contributor to moral injuries, it has yet to be examined empirically. In the current study, we examined the unique impact of moral judgment levels on the experience of PMIEs among combat veterans. We also examined the moderating role of moral judgment in the relationship between PMIEs and MI outcomes and depressive symptoms. A volunteer sample of 70 male Israeli combat veterans completed self-report questionnaires and a moral judgment task in a cross-sectional design study. Our findings indicate that moral judgment contributed to higher levels of perceiving others' actions as transgressive (PMIE-Other), above and beyond combat exposure. Moreover, we found that moral judgment has a moderating role in the link between PMIEs and their negative outcomes: Among veterans with higher levels of moral judgment, the association between PMIEs and their expressions was stronger than for those with lower levels of moral judgment. Our finding highlights the unique contribution of moral judgment level to PMIEs and their mental health consequences. It can be cautiously suggested that moral judgment should be viewed as a pre-recruitment risk factor that can help identify those at greater risk for mental health problems following exposure to PMIEs.

Moral injury and pre-deployment personality factors as contributors to psychiatric symptomatology among combatants: a two-year prospective study.

Background: Combatants who are exposed to events that transgress deeply held moral beliefs might face lasting psychopathological outcomes, referred to as Moral Injury (MI). However, knowledge about pre-deployment factors that might moderate the negative consequences of MI is sparse. In this prospective study, we examined pre-enlistment characteristics and pre-deployment personality factors as possible moderators in the link between exposure to potentially morally injurious events (PMIEs) and psychiatric symptomatology among Israeli active-duty combatants.Methods: A sample of 335 active-duty Israeli combatants participated in a 2.5-year prospective study with three waves of measurements (T1: 12 months before enlistment, T2: Six months following enlistment - pre-deployment, and T3: 18 months following enlistment - post-deployment). Participants' characteristics were assessed via semi-structured interviews (T1) and validated self-report measures of personality factors: emotional regulation, impulsivity, and aggression (T2) and combat exposure, PMIEs, psychiatric symptomology and posttraumatic symptoms (T3) between 2019 and 2021.Results: Pre-enlistment psychiatric difficulties and negative life events contributed to higher exposure to PMIEs post-deployment. Higher levels of pre-deployment aggression and lower levels of emotional regulation and impulsivity moderated the association between betrayal, PMIEs and psychiatric symptomology post-deployment, above and beyond pre-enlistment psychiatric difficulties and life events.Conclusions: Our results highlight that pre-deployment emotional regulation, impulsivity and aggressiveness levels should be assessed, screened, and identified among combatants, as they all facilitate psychiatric symptomology (and PTSS) after combatants are exposed to PMIEs of betrayal. Such pre-assessment will enable the identification of at-risk combatants and might provide them with tailor-made preparation regarding moral and ethical situations that should be investigated in future research.

Pre-enlistment psychiatric difficulties contributed to higher exposure to PMIEs post-deployment.Pre-deployment personality moderated the associations between PMIEs and psychiatric symptomatology among combatants.Higher levels of pre-deployment emotional regulation moderated the association between betrayal PMIEs and post-deployment PTSS symptoms.

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

BACKGROUND: Exposure 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. METHODS: Participants 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. RESULTS: Above 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. LIMITATIONS: We used self-report measures to assess PMIEs and SI, which may suffer from various biases. CONCLUSIONS: Our 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.

Potential Sources of Moral Injury for Healthcare Workers in Forensic and Psychiatric Settings: A Systematic Review and Meta-ethnography.

The current research examines potentially morally injurious events (PMIEs) faced by healthcare professionals working in forensic and psychiatric environments. A systematic literature review was conducted to identify peer-reviewed articles reporting on sources of moral injury or similar concepts (e.g., moral distress) for healthcare workers in such settings. Thirty articles were included and analyzed using a meta-ethnographic approach. Synthesis yielded three third-order factors, each reflecting a moral dichotomy: (a) "between profession and system," (b) "between relations with patients and relations with others," and (c) "between principles and practices." Findings illustrated the hierarchical relationships between dichotomies, with discordance between values of the healthcare profession and features of the healthcare system providing the conditions for PMIEs to occur. The review advances conceptual understandings of PMIEs in forensic and psychiatric settings, illustrating the multilayered dimensions within which morally injurious events are experienced. Theoretical and practical implications are offered that may support the early detection and prevention of moral injury in healthcare professionals.

Longitudinal associations between transgressions of moral beliefs and suicidal ideation among recently discharged veterans.

We evaluated longitudinal associations between subjective appraisals of transgressions of moral beliefs, values, and expectations (potential morally injurious events; PMIEs) and suicidal ideation (SI) among recently discharged combat veterans. Participants 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 discharge (T3 and T4, respectively). A history of lifetime suicidal ideation and behavior was associated with higher levels of subjective appraisals of PMIEs, as compared to no history of suicidal ideation and behavior. Above and beyond pre-enlistment personal characteristics, cross-lagged pathway analyses indicated significant bi-directional pathways between subjective appraisals of PMIEs and SI. For all PMIEs dimensions, SI was associated with greater subjective appraisals of PMIEs, on subsequent measurement. However, cross-lagged effects of PMIEs-'other' (T2) predicting SI (T3) and PMIEs-'betrayal' (T3) predicting SI (T4) were also found. Our findings are the first to provide evidence of longitudinal, temporal associations between subjective appraisals of PMIEs and SI, which might serve as potential intervention targets among recently discharged traumatized veterans.

Pre-deployment aggressiveness, combat exposure and moral injury as contributors to posttraumatic stress symptoms among combatants: A two-year prospective study.

Combatants who are exposed to events which transgress deeply held moral beliefs might face lasting psychopathological outcomes such as Moral Injury (MI) and posttraumatic stress symptoms (PTSS). However, insight about pre-deployment personality factors which might facilitate the MI process and its negative consequences is sparse. In this prospective study, we examined pre-deployment aggressiveness as a possible predictor of exposure to combat and potentially morally injurious events (PMIEs), trauma-related guilt and shame and PTSS among Israeli active-duty combatants. A sample of 335 active-duty Israeli combatants participated in a 2.5-year prospective study with three waves of measurements (T1: 12 months before enlistment, T2: 6 months following enlistment-pre deployment, and T3: 18 months following enlistment-post deployment). Participants' characteristics were assessed via semi-structured interviews (T1) and validated self-report measures of aggressiveness (T2), combat exposure, PMIEs and PTSS (T3) between 2019 and 2021. Results show that higher levels of pre-deployment aggressiveness predicted both combat exposure and PMIEs-'betrayal'. Combat exposure mediated the association between aggressiveness and PTSS post deployment. Importantly, pre-deployment aggressiveness was significantly associated with the PMIEs-'betrayal' that are associated with trauma-related guilt and shame, which in turn were associated with high levels of PTSS post deployment. Our results highlight the implications of pre-deployment aggressiveness for different forms of exposure to potentially traumatic events during military service. Identification of at-risk combatants for PTSS following exposure to PMIEs of betrayal might provide these combatants with a tailor-made type of preparation regarding moral and ethical situations, which should be investigated in future studies.

Exposure to potentially morally injurious events, disruption in assumptive world, moral injury symptoms, and psychological distress among Israeli female veterans.

Exposure to potentially morally injurious events (PMIEs) during military service is associated with mental health problems. However, knowledge about these associations and possible mechanisms of effect among female combat veterans is sparse. This study examines associations between PMIEs, posttraumatic stress disorder (PTSD), complex PTSD, depression and anxiety symptoms among female veterans, as well as the mediating role of disruption in assumptive world and moral injury (MI) symptoms. A volunteer sample of Israeli female combat veterans (n = 885) and non-combat veterans (n = 728) responded to self-report questionnaires in a cross-sectional design study. Results show that combat veterans reported higher levels of PMIEs, PTSD and MI symptoms, but not CPTSD, depression and anxiety symptoms, as compared to non-combat veterans. Importantly, PMIEs was indirectly associated with PTSD, complex PTSD, depression and anxiety symptoms through serial mediators of disruption in assumptive world and MI symptoms. This study emphasized the exposure to PMIEs and its posttraumatic sequelae among female combat veterans as compared to non-combat veterans. Our findings also suggest that future longitudinal studies should examine the mediating role of disruption in assumptive world and MI symptoms for the deleterious effects of exposure to PMIEs during military service.

'It hurts your heart': frontline healthcare worker experiences of moral injury during the COVID-19 pandemic.

Background: Moral injury is defined as the strong emotional and cognitive reactions following events which clash with someone's moral code, values or expectations. During the COVID-19 pandemic, increased exposure to Potentially Morally Injurious Events (PMIEs) has placed healthcare workers (HCWs) at risk of moral injury. Yet little is known about the lived experience of cumulative PMIE exposure and how NHS staff respond to this. Objective: We sought to rectify this knowledge gap by qualitatively exploring the lived experiences and perspectives of clinical frontline NHS staff who responded to COVID-19. Methods: We recruited a diverse sample of 30 clinical frontline HCWs from the NHS CHECK study cohort, for single time point qualitative interviews. All participants endorsed at least one item on the 9-item Moral Injury Events Scale (MIES) [Nash et al., 2013. Psychometric evaluation of the moral injury events scale. Military Medicine, 178(6), 646-652] at six month follow up. Interviews followed a semi-structured guide and were analysed using reflexive thematic analysis. Results: HCWs described being routinely exposed to ethical conflicts, created by exacerbations of pre-existing systemic issues including inadequate staffing and resourcing. We found that HCWs experienced a range of mental health symptoms primarily related to perceptions of institutional betrayal as well as feeling unable to fulfil their duty of care towards patients. Conclusion: These results suggest that a multi-facetted organisational strategy is warranted to prepare for PMIE exposure, promote opportunities for resolution of symptoms associated with moral injury and prevent organisational disengagement. HIGHLIGHTS Clinical frontline healthcare workers (HCWs) have been exposed to an accumulation of potentially morally injurious events (PMIEs) throughout the COVID-19 pandemic, including feeling betrayed by both government and NHS leaders as well as feeling unable to provide duty of care to patients.HCWs described the significant adverse impact of this exposure on their mental health, including increased anxiety and depression symptoms and sleep disturbance.Most HCWs interviewed believed that organisational change within the NHS was necessary to prevent excess PMIE exposure and promote resolution of moral distress.

Antecedentes: El daño moral se define como las fuertes reacciones emocionales y cognitivas que siguen a los eventos que chocan con el código moral de una persona, sus valores o expectativas. Durante la pandemia de COVID-19, el aumento de la exposición a Eventos Potencialmente Dañinos para la Moral (PMIEs, por su sigla en inglés) ha puesto a los trabajadores de la salud (HCWs, por su sigla en inglés) en riesgo de daño moral. Aún se conoce poco sobre la experiencia vivida de la exposición acumulada a PMIE y cómo el personal del Servicio Nacional de Salud de Inglaterra (NHS en su sigla en inglés) responde a esto.Objetivo: Buscamos rectificar esta brecha de conocimiento a través de la exploración cualitativa de las experiencias vividas y perspectivas del personal clínico de primera línea de NHS que respondió al COVID-19.Métodos: Reclutamos una muestra diversa de 30 HCWs clínicos de primera línea de la cohorte del estudio CHECK del NHS, para entrevistas cualitativas de una sola vez. Todos los participantes aprobaron al menos un ítem de los 9 de la Escala de Eventos de Daño Moral (MIES) [Nash y cols., 2013. Psychometric evaluation of the moral injury events scale. Military Medicine, 178(6), 646­652] en el seguimiento a los 6 meses. Las entrevistas siguieron una guía semi-estructurada y fueron analizadas utilizando análisis temático reflexivo.Resultados: Los HCWs describieron estar expuestos de forma rutinaria a conflictos éticos, creados por exacerbación de problemas sistémicos pre-existentes que incluían falta de personal y de recursos. Encontramos que los HCWs experimentaron un rango de síntomas de salud mental primariamente relacionados a percepciones de traición institucional y al sentirse incapaces de cumplir con su deber de cuidado hacia los pacientes.Conclusión: Estos resultados sugieren que se requiere una estrategia organizacional multifacética para preparar para la exposición a PMIE fomentar oportunidades de resolución de los síntomas asociados al daño moral y prevenir la separación organizacional.

The wounded helper: moral injury contributes to depression and anxiety among Israeli health and social care workers during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic can affect the mental health of health and social care workers (HSCWs) who are frontline workers in this crisis. The pandemic poses unique challenges to HSCWs as they face morally daunting decisions while working with limited knowledge and resources. This study examined the relationships between exposure to potentially morally injurious events (PMIEs) and depression and anxiety among HSCWs. METHOD: A sample of 243 Israeli HSCWs completed validated self-report questionnaires that include measures of depression, anxiety, exposure to PMIEs, perceived stress, and moral injury symptoms. RESULTS: About one-third (33.6%) of the sample met the criteria for major depressive disorder, 21.5% met the criteria for generalized anxiety disorder, and 19.1% reported comorbidity of depression and anxiety. Beyond demographic, COVID-19, and work-related characteristics, PMIEs contributed to depression and anxiety among HSCWs. The integrative model indicated the mediating role of perceived stress and moral injury symptoms in the associations of PMIEs with depression and anxiety. CONCLUSIONS: The study's findings highlight HSCWs' mental burden during the COVID-19 pandemic and the important contribution of exposure to PMIEs to this burden. Clinicians treating HSCWs coping with depression and anxiety following the COVID-19 should also attend to moral injury symptoms.

Help-seeking for mental health issues in deployed Canadian Armed Forces personnel at risk for moral injury.

Objective: Potentially morally injurious experiences (PMIE) (events that transgress an individual's subjective moral standards) have been associated with psychologically distressing moral emotions such as shame and guilt. Military leaders and clinicians have feared that those with PMIEs may be less likely to seek help due to the withdrawing nature of shame/guilt; however, to date, help-seeking patterns of military personnel with PMIEs has not been explored. Our objective is to address this research gap. Method: Data from a nationally-representative mental health survey of active Canadian military personnel were analysed. To assess the association between exposure to three PMIEs and past-year help-seeking across different provider categories (i.e. professionals, para-professionals (those delegated with mental health advisory tasks but are not licenced to practice as medical professionals), non-professionals), a series of logistic regressions were conducted, controlling for exposure to other deployment and non-deployment-related psychological trauma, psychiatric variables, military factors, and sociodemographic variables. Analytical data frame included only personnel with a history of Afghanistan deployment (N = 4854). Results: Deployed members exposed to PMIEs were more likely to seek help from their family doctor/general practitioner (OR = 1.72; 95%CI = 1.25-2.36), paraprofessionals (OR = 1.72; 95%CI = 1.25-2.36), and non-professionals (OR = 1.44; 95%CI = 1.06-1.95) in comparison to members not exposed to PMIEs. Those exposed to PMIEs were also more likely to seek professional care from the civilian health care system (OR = 1.94; 95%CI = 1.27-2.96). Conclusion: Contrary to long-held, but untested, assumptions regarding the impact of PMIEs on help-seeking, we found those with PMIEs are more likely to seek help from gatekeeper professionals (i.e. general practitioners), para-professionals, and non-professionals rather than specialized mental health professionals (e.g. psychologists). Increased utilization of civilian professionals raises concerns that active military members may be avoiding military health services. Clinically, this highlights the need to increase awareness of moral injury to ensure that actively serving military members are provided with appropriate advice and treatment.

Objetivo: Las experiencias potencialmente dañinas para la moral (PMIE por sus siglas en inglés), definidas como eventos que transgreden los estándares morales subjetivos de un individuo, han sido asociadas con emociones angustiantes relacionadas con la moral, como la vergüenza y la culpa. Los líderes militares y los clínicos han temido que aquellos que experimentan PMIEs tienen menos probabilidades de buscar ayuda debido a la naturaleza aislante de la vergüenza y la culpa, sin embargo a la fecha, los patrones de búsqueda de ayuda del personal militar con PMIEs no han sido explorados. Nuestro objetivo es abordar esta brecha.Método: se analizaron datos de una encuesta de salud mental para personal militar canadiense en servicio activo. La encuesta era representativa de todo el país y de corte transversal. Para evaluar la asociación entre exposición a tres PMIEs y búsqueda de ayuda durante el último año a través de diferentes categorías de proveedores (tales como no profesionales o aquellos militares delegados con tareas de salud mental), se realizó una serie de regresiones logísticas, controlando para exposición a otros despliegues y trauma no relacionado a los despliegues, variables psiquiátricas, factores militares y variables sociodemográficas. El marco de datos analítico incluyó solo personal CAF activo con una historia de despliegue en Afganistán (n=4854).Resultados: Los sujetos en despliegue expuestos a PMIEs tenían más probabilidad de buscar ayuda de parte de su médico de familia/médico general (OR=1.72; 95% CI=1.25-2.36), paraprofesionales (OR=1.72; 95%CI=1.25-2.36), y no profesionales (OR=1.44; 95%CI=1.06-1.95) en comparación con aquellos sujetos no expuestos a PMIEs. Aquellos expuestos a PMIEs también tenían más probabilidad de buscar ayuda profesional en el sistema de salud civil (OR=1.94; 95%CI=1.27-2.96).Conclusión: Al contrario de la creencia por largo tiempo sostenida, pero no probada en relación al impacto de las PMIEs en la búsqueda de ayuda, encontramos que aquellos con PMIEs tienen más probabilidades de buscar ayuda de profesionales de puerta de entrada (como médicos generales) y de no profesionales en vez de profesionales especializados en salud mental (como psicólogos). El aumento de la consulta en profesionales civiles plantea la preocupación de que militares activos puedan estar evitando los servicios de salud militares. Clínicamente, esto destaca la necesidad de aumentar la concientización sobre el daño moral para asegurar que los militares en servicio activo sean proveídos con apropiada consejería y tratamiento.