Moral injury (MI) refers to the distress experienced when people do, or do not, do something that goes against their morals or values. It can also occur when people perceive that their values have been betrayed. MI is associated with several mental health conditions, including posttraumatic stress disorder (PTSD), depression, and anxiety. A potential risk factor for MI may include difficulties with emotion regulation (ER). Difficulties with ER refers to the ability to manage emotions. It is associated with the same mental health conditions linked to MI, including PTSD. The purpose of this study was to examine whether difficulties with ER were associated with MI in a Canadian military personnel and Veteran sample. Participants completed several questionnaires assessing for MI, difficulties with ER, and other mental health symptoms, such as PTSD, while they were inpatients at a psychiatric hospital. It was found that MI and perceived betrayals were associated with symptoms of PTSD. Symptoms of PTSD, depression, and anxiety were also associated with one another. Difficulties with ER were also associated with symptoms of PTSD, depression, and anxiety but were not related to MI. The findings serve as a first step in examining potential risk factors of MI.
Introduction: Moral injury (MI) refers to the psychological distress associated with perceived betrayals or perceived transgressions of one’s moral values. It has been studied primarily among military personnel and Veterans and has been found to be associated with posttraumatic stress disorder (PTSD), depression, anxiety, and other psychiatric symptoms. Recently, research has begun to investigate MI and its potential risk factors. Difficulties with emotion regulation (ER), which refers to difficulties with managing and moderating emotions, is a transdiagnostic factor associated with several psychiatric conditions, including PTSD, depression, and anxiety. The objective of the current study was to investigate the relations among MI; symptoms of PTSD, depression, anxiety, and stress; and difficulties with ER in a sample of Canadian military personnel and Veterans. A secondary aim was to discuss the potential relevance of these relations for military personnel, Veterans, and front-line health care workers during the COVID-19 pandemic. Methods: Assessments of MI, PTSD, depression, anxiety, stress, and difficulties with ER were administered to Canadian military personnel and Veterans. Correlational analyses were used to assess the relation of MI to these symptoms. Results: Increased levels of MI were associated with avoidance and alterations in mood and cognition symptom clusters of PTSD. Perceived betrayals were also significantly correlated with PTSD-related alterations in mood and cognition symptoms. Symptoms of PTSD were significantly associated with depression, anxiety, and stress. Difficulties with ER were significantly correlated with symptoms of PTSD, depression, anxiety, and stress, but not with MI (p = 0.07). Discussion: These results reveal an association between MI and specific symptom clusters of PTSD, and they highlight the association between difficulties with ER and symptoms of psychiatric illness among Canadian military personnel and Veterans. The potential implications of these findings and future work examining MI in military personnel, Veterans, and front-line health care workers during the COVID-19 pandemic are discussed.
Introduction : Le préjudice moral (PM) désigne la détresse psychologique découlant des perceptions de trahison et de transgression de ses propres valeurs morales. Il a surtout été étudié chez les membres du personnel militaire et les vétérans, et il a été établi qu’il est associé au trouble de stress post-traumatique (TSPT), à la dépression, à l’anxiété et à d’autres symptômes psychiatriques. Récemment, les recherches ont commencé à porter sur les facteurs de risque potentiels du PM. Les troubles de régulation affective (RA), qui désignent les difficultés à gérer et à modérer ses émotions, sont des facteurs transdiagnostiques liés à divers troubles psychiatriques, y compris le TSPT, la dépression et l’anxiété. La présente étude vise à examiner les relations entre le PM, les symptômes de TSPT, la dépression, l’anxiété, le stress et les troubles de RA auprès d’un échantillon de membres du personnel militaire et de vétérans canadiens. Un objectif secondaire consistait à examiner la pertinence potentielle de ces relations pour le personnel militaire, les vétérans et les travailleurs de la santé de première ligne pendant la pandémie de COVID-19. Méthodologie : Les chercheurs ont évalué le PM, le TSPT, la dépression, l’anxiété, le stress et les troubles de RA du personnel militaire et des vétérans. Ils ont utilisé des analyses de corrélation pour évaluer le lien entre le PM et ces symptômes. Résultats : Un taux élevé de PM était relié de manière significative aux grappes d’évitement, de perturbations de l’humeur et de symptômes cognitifs relatifs aux TSPT. La perception de trahison était également associée de manière significative aux perturbations de l’humeur et aux symptômes cognitifs liés aux TSPT. Les symptômes de TSPT avaient un lien significatif avec la dépression, l’anxiété et le stress. Les troubles de RA étaient corrélés de manière significative avec les symptômes de TSPT, la dépression, l’anxiété et le stress, mais pas avec le PM (p = 0,07). Discussion : Ces résultats révèlent une association entre le PM et des grappes précises de symptômes de TSPT et font ressortir le lien entre les troubles de RA et les symptômes de maladie psychiatrique chez les membres du personnel militaire et les vétérans canadiens. Les répercussions potentielles de ces constatations et les futurs travaux sur le PM chez les membres du personnel militaire, les vétérans et les travailleurs de première ligne pendant la pandémie de COVID-19 sont abordés.
The Canadian Armed Forces (CAF) employs more than 100,000 individuals,1 with personnel distributed across the globe.2 Critically, the CAF faces unconventional and asymmetric warfare in the combat theatre, involving ill-defined enemies and the presence of what may be perceived as morally ambiguous objectives. A burgeoning area of research suggests that military personnel exposed to these situations have the potential to develop moral injury (MI),3-5 defined as the psychological distress associated with committing, failing to prevent, observing, or learning about an event that violates one’s moral and ethical values.3 MI may result in response to a person’s own acts of omission or commission (i.e., perceived transgressions) or through witnessing acts of omission or commission by an authoritative individual or group, resulting in a sense of betrayal.3,5 Specifically, Litz and colleagues have suggested that the ambiguous context of some combat (e.g., difficulty discriminating between enemies and civilians, guerrilla warfare, rules of engagement limiting assistance to bystanders) and the other roles that military personnel are assigned (e.g., peacekeeping, stabilization, crises work) may expose personnel to situations in which they are required to act in a manner that may or may not be in keeping with their ethical and moral values.3
Notably, MI has been associated with numerous psychological difficulties, including posttraumatic stress disorder (PTSD), major depressive disorder (MDD),6,7 anxiety,7 suicidal ideation, difficulties with social functioning,4 loss of trust and spirituality, and feelings of guilt and shame. Preliminary work has begun to examine potential risk factors for MI in an effort to identify those individuals who are more susceptible to the development of distress after a morally injurious event.8,9 Here, qualitative work in a Veteran sample has identified that MI could occur after events in which loss of vulnerable persons occurs.8 Moreover, perceived lack of support from leaders, friends, and families, as well as perceived lack of responsibility from leadership, were also indicated as risk factors for the development of distress after a morally injurious event. Veterans also reported that perceived unawareness of the potential emotional and psychological consequences of their actions, or lack of actions; concurrent exposure to other traumatic events or life stressors; and lower educational attainment may contribute to the risk of developing MI. In addition, a study examining a sample of Canadian military personnel and Veterans found that childhood emotional abuse was significantly associated with MI during adulthood,9 suggesting that it may also confer risk in the development of MI.
Difficulties with emotion regulation may also constitute another risk factor for the development of MI among military personnel and Veterans, but it remains unexplored in this population. Specifically, difficulties with emotion regulation have been linked to PTSD,10,11 MDD,12 anxiety disorders,13 and borderline personality disorder,14,15 including among military personnel and Veterans. Emotion regulation includes the ability to manage and moderate emotional responses.16 Notably, difficulties with emotion regulation have been identified as a transdiagnostic factor and a mechanism of symptom expression and severity in psychiatric disorders, where as difficulty with emotion regulation increases, psychological symptom expression and severity worsen.17-19 Consequently, difficulty with emotion regulation is a linking factor across several psychological and emotional conditions and may subsequently play a critical role in the relations among MI and other psychiatric conditions.
The effort to identify risk factors of MI, such as difficulties with emotion regulation, may help to identify those individuals who are more susceptible to the development of distress after a morally injurious event and who may subsequently require additional support services and treatment. Notably, this effort may be relevant during the COVID-19 pandemic, in which Canadian military personnel have been tasked with assisting and supporting the Government of Canada’s pandemic response.20 Here, military personnel may also have been exposed to moral and ethical dilemmas. For example, military personnel were tasked with assisting front-line health care workers to provide care in long-term-care facilities in Ontario and Quebec.20 Accordingly, a report by the Department of National Defence and the CAF was released after the military’s involvement in long-term-care facilities, which detailed the deplorable conditions nursing home residents were living in, including how residents were found in soiled bedding after days of neglect.21 These findings demonstrate the potential of encountering morally injurious events, including bearing witness to the pain and suffering among patients and their families, during the COVID-19 pandemic. Such events may transgress the central dictums of medical care and front-line intervention, which may also increase the susceptibility to experiencing a MI.
Therefore, given the dearth of Canadian research examining MI and its potential risk factors, the objective of this study was to investigate the relations among MI, psychological symptoms, and difficulties with emotion regulation in a sample of Canadian military personnel and Veterans. An additional goal was to discuss the potential relevance of such findings for military personnel, Veterans, and other front-line health care workers in the context of the COVID-19 pandemic.
Data for this study were collected via Research-Ethics-Board-approved retrospective chart review of standardized assessment batteries administered to all newly admitted patients at the Program for Traumatic Stress Recovery (PTSR) at Homewood Health Centre in Guelph, Ontario, Canada, between May 22, 2015, and June 30, 2016. These data were also combined with data collected prospectively at the centre between August 2017 and November 2019. Of the 634 unique individuals included in the retrospective and prospective sample, 128 participants identified as being either active military personnel or Veterans and were included in the sample.
Demographic information were requested from the Resident Assessment Instrument-Mental Health Assessment, an assessment mandated by the Ontario Ministry of Health and Long-Term Care for the collection of clinical and administrative data. Participants were excluded from the analyses on the basis of missing or incomplete data (n = 32; listwise deletion based on missing data from any variable in the analysis) and also for simultaneously identifying as military personnel or Veterans and public safety personnel (n = 23), leaving a final sample of 73 military personnel and Veterans. Patients were admitted to the PTSR unit on the basis of presumed exposure to traumatic events. Demographic and clinical characteristics of the sample are reported in Table 1. Data from a subset of participants from the current study (based on available data; samples are not identical) also appear in other reports.9,22,23
MI was assessed using the Moral Injury Events Scale (MIES),24 which was adapted for the Canadian military context. Patients rated their agreement on a nine-item self-report measure, which assessed MI along two dimensions — perceived betrayals (MIES Betrayal sub-scale) and perceived transgressions (MIES Transgression sub-scale). High internal consistency coefficients for the MIES have been reported for a military sample in the United States (Cronbach’s α = 0.90).24 In the current sample, Cronbach’s α was 0.87 for the MIES total score.
|Sample (N = 73)|
|Demographic characteristics, n (%)*|
|Age, mean, (SD)||43.7 (9.3)|
|Never married||13 (17.8)|
|Married or common law||41 (56.2)|
|Living with partner or significant other||4 (5.5)|
|≤ 8th grade||1 (1.4)|
|Some high school||8 (11.0)|
|High school||16 (21.9)|
|Technical or trade school||11 (15.1)|
|Some college or university||19 (26.0)|
|Diploma or bachelor’s degree||11 (15.1)|
|Graduate degree||7 (9.6)|
|Employment insurance||5 (6.8)|
|Social assistance||1 (1.4)|
|Disability insurance||18 (24.7)|
|Other (e.g., investment, WSIB, inheritance)||12 (16.4)|
|No income||2 (2.7)|
|Clinical characteristics, mean (SD)|
|MIES Transgress||23.5 (9.8)|
|MIES Betrayal||13.1 (4.6)|
|MIES Total score||36.6 (12.4)|
|Posttraumatic stress symptoms|
|PCL-5 Intrusions||14.3 (4.3)|
|PCL-5 Avoidance||6.2 (1.9)|
|PCL-5 Mood and Cognitions||21.6 (4.4)|
|PCL-5 Reactivity||17.6 (3.8)|
|PCL-5 Total score||59.6 (11.9)|
|Depression, anxiety, and stress symptoms|
|DASS-21 Depression||28.1 (10.9)|
|DASS-21 Anxiety||23.5 (9.6)|
|DASS-21 Stress||28.7 (8.2)|
|DERS Nonacceptance||21.3 (7.4)|
|DERS Goals||20.5 (4.5)|
|DERS Impulse||18.4 (6.4)|
|DERS Awareness||21.1 (5.0)|
|DERS Strategies||28.6 (7.3)|
|DERS Clarity||16.7 (4.2)|
|DERS Total score||126.5 (25.3)|
Note: Percentages may not total 100 because of rounding.
*Unless otherwise indicated.
WSIB = Workplace Safety and Insurance Board; MIES = Moral Injury Events Scale; Transgress = Transgression sub-scale; Betrayal = Betrayal sub-scale; PCL-5 = PTSD Checklist for DSM-5; Intrusions = Intrusions sub-scale; Avoidance = Avoidance sub-scale; Mood and Cognitions = Negative Alterations in Mood and Cognitions sub-scale; Reactivity = Arousal and Reactivity sub-scale; DASS-21 = Depression, Anxiety, and Stress Scale; Depression = Depression sub-scale; Anxiety = Anxiety sub-scale; Stress = Stress sub-scale; DERS = Difficulties in Emotion Regulation Scale; Nonacceptance = Nonacceptance sub-scale; Goals = Goals sub-scale; Impulse = Impulse Sub-scale; Awareness = Awareness sub-scale; Strategies = Strategies sub-scale; Clarity = Clarity sub-scale.
The PTSD Checklist for DSM-5 (PCL-5) was administered to patients to assess the severity of PTSD symptoms (PCL-5 total score) according to the diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5).25,26 The symptom domains included intrusive symptoms (PCL-5 Intrusions sub-scale), avoidance (PCL-5 Avoidance sub-scale), negative alterations in mood and cognitions (PCL-5 Negative Alterations in Moods and Cognitions sub-scale), and alterations in arousal and reactivity (PCL-5 Arousal and Reactivity sub-scale). The PCL-5 shows high internal consistency in military (Cronbach’s α = 0.95) and Veteran (Cronbach’s α = 0.95) samples.27,28 In the current sample, Cronbach’s α was 0.90 for the PCL-5 total score.
The 21-item version of the Depression, Anxiety, and Stress Scale (DASS-21) was administered to assess the severity and presence of symptoms related to depression (DASS-21 Depression sub-scale), anxiety (DASS-21 Anxiety sub-scale), and stress (DASS-21 Stress sub-scale) within the past week.29 The DASS-21 has been shown to have good internal consistency (Cronbach’s α = 0.73-0.81). Here, the Cronbach’s α values were 0.89, 0.81, and 0.79 for the Depression, Anxiety, and Stress sub-scales, respectively.
The Difficulties in Emotion Regulation Scale (DERS),16 a 36-item self-report measure, was used to assess challenges with emotion regulation across six domains — difficulties with accepting negative emotions (DERS Nonacceptance sub-scale), difficulties completing tasks because of negative emotions (DERS Goals sub-scale), difficulties with controlling impulses while experiencing distressing emotions (DERS Impulse sub-scale), difficulties with awareness of emotional experiences (DERS Awareness sub-scale), negative beliefs regarding the ability to regulate emotions (DERS Strategies sub-scale), and difficulties with insight regarding emotions (DERS Clarity sub-scale). Higher scores indicate greater dysfunction with emotion regulation. The DERS has been shown to have good psychometric properties, including internal consistency and construct validity.16 In the current sample, Cronbach’s α was 0.94 for the DERS total score.
Data were analyzed using IBM SPSS Statistics version 26.0 (IBM Corporation, Armonk, NY). Analyses were preceded by tests of normality. Measures and their sub-scales were found to be non-normal. Therefore, non-parametric analyses were performed. Given the small sample size, to determine whether MI and symptoms of PTSD, depression, anxiety, and stress were associated with difficulties with emotion regulation, correlation analyses (i.e., Spearman’s rs) controlling for age and sex were performed. Analyses were two-tailed, and α was set at 0.05.
The mean MI score was 36.6 (SD = 12.4), with a range of scores falling between 9 and 54. Moreover, the mean symptom severities for PTSD, depression, anxiety, stress, and difficulties with emotion regulation were 59.6 (SD = 11.9), 28.1 (SD = 10.9), 23.5 (SD = 9.6), 28.7 (SD = 8.2), and 126.5 (SD = 25.3), respectively.
Significant positive correlations were found between MI and symptoms of PTSD avoidance (rs = 0.3, p = 0.03; Table 2) and MI and alterations in cognition and mood symptoms related to PTSD (rs = 0.2, p = 0.04). Perceived betrayals also correlated significantly with alterations in cognition and mood symptoms (rs = 0.3, p = 0.02). No significant correlations were found among MI, perceived transgressions, and perceived betrayals with PTSD symptom severity (rs = 0.2, p = 0.06; rs = 0.2, p = 0.1; and rs = 0.2, p = 0.06, respectively), depression (rs = 0.2, p = 0.08; rs = 0.2, p = 0.1; and rs = 0.2, p = 0.1, respectively), anxiety (rs = 0.1, p = 0.3; rs = 0.1, p = 0.2; and rs = 0.03, p = 0.8, respectively), or stress (rs = 0.1, p = 0.2; rs = 0.09, p = 0.4; and rs = 0.2, p = 0.1, respectively) symptoms. Perceived transgressions and perceived betrayals were not significantly associated with difficulties with emotion regulation (rs = 0.2, p = 0.1, and rs = 0.2, p = 0.1, respectively). MI and difficulties with emotion regulation approached significance, but did not reach the α threshold (i.e., rs = 0.2, p = 0.07).
PTSD symptom severity correlated significantly with depression (rs = 0.6, p < 0.001), anxiety (rs = 0.6, p < 0.001), and stress (rs = 0.6, p < 0.001) symptoms. Difficulties with emotion regulation were also correlated significantly with PTSD (rs = 0.6, p < 0.001), depression (rs = 0.7, p < 0.001), anxiety (rs = 0.6, p < 0.001), and stress (rs = 0.7, p < 0.001) symptoms.
This study is the first to examine the relations among MI, symptoms of PTSD, depression, anxiety, and stress, and difficulties with emotion regulation in a Canadian military personnel and Veteran sample. Here, significant positive correlations emerged between levels of self-reported MI and symptoms of PTSD-related avoidance (DSM-5 cluster C criteria for a diagnosis of PTSD) and alterations in cognition and mood (DSM-5 cluster D criteria for diagnosis of PTSD),26 which are findings in keeping with previous work demonstrating a link between symptoms of PTSD and MI.6,7 Notably, the relation between symptoms of MI and PTSD-related avoidance may support previous research that has found that individuals with MI experience challenges with social functioning.4 Specifically, challenges related to social functioning may be associated with feelings of guilt (i.e., feeling as though one is at fault for a specific outcome) and shame (i.e., negative global self-evaluations),30 which are symptoms found within PTSD cluster D criteria. Critically, guilt and shame are generally believed to drive social avoidance and withdrawal from others.30 Within the context of MI, these emotions may elicit the belief that one’s behaviours (i.e., actions or inactions) have caused irreparable harm,31,32 leading to avoidance of reminders of one’s actions and detachment from others, because individuals with MI may not want others to see the “stain on [their] soul.”33(p. 413)
|1. MIES Transgress||–||0.4†||1.0†||0.06||0.2||0.2||0.2||0.2||0.2||0.1||0.09||0.1||0.2||0.2||0.08||0.2||0.1||0.2|
|2. MIES Betrayal||–||0.7†||0.05||0.2||0.3*||0.1||0.2||0.2||0.03||0.2||0.1||0.2||0.09||0.01||0.2||0.2||0.2|
|3. MIES Total score||–||0.05||0.3*||0.2*||0.2||0.2||0.2||0.1||0.1||0.1||0.2||0.2||0.08||0.2||0.1||0.2|
|4. PCL-5 Intrusions||–||0.4†||0.5†||0.5†||0.8†||0.4†||0.5†||0.4†||0.3*||0.3*||0.2*||0.05||0.2||0.3*||0.3*|
|5. PCL-5 Avoidance||–||0.4†||0.3*||0.6†||0.3*||0.4†||0.3*||0.3*||0.4†||0.3*||0.2||0.2||0.3*||0.4†|
|6. PCL-5 Mood and Cognitions||–||0.7†||0.9†||0.6†||0.5†||0.6†||0.5†||0.3†||0.5†||0.2||0.4†||0.5†||0.6†|
|7. PCL-5 Reactivity||–||0.8†||0.4†||0.5†||0.6†||0.4†||0.4†||0.6†||0.2||0.4†||0.4†||0.6†|
|8. PCL-5 Total score||–||0.6†||0.6†||0.6†||0.4†||0.5†||0.5†||0.2||0.4†||0.5†||0.6†|
|9. DASS-21 Depression||–||0.6†||0.6†||0.6†||0.4†||0.5†||0.4†||0.6†||0.5†||0.7†|
|10. DASS-21 Anxiety||–||0.8†||0.5†||0.4†||0.6†||0.1||0.5†||0.4†||0.6†|
|11. DASS-21 Stress||–||0.6†||0.5†||0.6†||0.1||0.6†||0.5†||0.7†|
|12. DERS Nonacceptance||–||0.6†||0.5†||–0.04||0.7†||0.4†||0.8†|
|13. DERS Goals||–||0.6†||0.2||0.7†||0.4†||0.8†|
|14. DERS Impulse||–||0.06||0.6†||0.3†||0.7†|
|15. DERS Awareness||–||0.2*||0.5†||0.4†|
|16. DERS Strategies||–||0.4†||0.9†|
|17. DERS Clarity||–||0.6†|
|18. DERS Total score||–|
Note: Spearman’s rs correlations for a sample of Canadian military and Veteran participants (N = 73).
*p ≤ 0.05 (two-tailed).
†p ≤ 0.01 (two-tailed).
MIES = Moral Injury Events Scale; Transgress = Transgression sub-scale; Betrayal = Betrayal sub-scale; PCL-5 = PTSD Checklist for DSM-5; Intrusions = Intrusions sub-scale; Avoidance = Avoidance sub-scale; Mood and Cognitions = Negative Alterations in Mood and Cognitions sub-scale; Reactivity = Arousal and Reactivity sub-scale; DASS-21 = Depression, Anxiety, and Stress Scale; Depression = Depression sub-scale; Anxiety = Anxiety sub-scale; Stress = Stress sub-scale; DERS = Difficulties in Emotion Regulation Scale; Nonacceptance = Nonacceptance sub-scale; Goals = Goals sub-scale; Impulse = Impulse Sub-scale; Awareness = Awareness sub-scale; Strategies = Strategies sub-scale; Clarity = Clarity sub-scale.
Moreover, these associations may also be supported by the link found between perceived betrayals and alterations in cognitions and mood (i.e., PTSD cluster D criteria). Specifically, when betrayal occurs in the context of an interpersonal or institutional relationship, it may elicit several psychological and behavioural responses, such as avoidance behaviours.34-36 More important, betrayal can occur in the military context as a result of its hierarchical organization,3,4,37,38 such as when an individual does not receive acknowledgement from his or her superiors if injuries are sustained during warfare or if one experiences within-rank violence, such as sexual assault.4,37
Moreover, difficulties with emotion regulation among military personnel and Veterans were associated with heightened symptoms of PTSD, depression, anxiety, and stress (ps < 0.001). These findings are consistent with earlier reports in the literature,10-13 in which, for example, the use of maladaptive emotion regulation strategies, such as rumination and non-acceptance of emotional experiences,12 is thought to contribute to the maintenance of depressive symptomatology and severity, anxiety symptoms,13 and PTSD.10,11 Together, this constellation of symptoms is associated with negative outcomes among military personnel and Veterans, including social and occupational withdrawal, increased mental health service utilization, and difficulties with the transition to civilian life,39 which warrants continued investigation of potential risk factors and potential treatments for MI.
Of note, the associations among MI, perceived transgressions, and perceived betrayals with PTSD symptom severity, depression, anxiety, and stress symptoms were not significant. Furthermore, the relations among difficulties with emotion regulation, MI, and its subsequent dimensions (i.e., perceived transgressions and betrayals) also did not reach the threshold for significance. This is contrary to our prediction that MI and difficulties with emotion regulation are associated with one another. Critically, these non-significant findings may be due to several limitations of the study. In particular, the current study is limited by a relatively small sample size. Future work should aim to replicate these findings with a larger sample. Moreover, clinical data were partly acquired through a retrospective medical chart review, as well as through data collected at one time point, making this study cross-sectional in nature. Accordingly, no conclusions regarding the temporal nature of the relations among the variables may be drawn (i.e., whether symptoms of PTSD made individuals more susceptible to developing MI or vice versa). Future studies may address these issues by using prospective data collection. In addition, clinical data should be collected using structured clinical interviews to confirm the findings from the self-report measures and to assess the index traumas, as well as to confirm exposures to potentially morally injurious events.
An additional weakness of the study includes the use of the MIES.24 Specifically, the MIES makes it difficult to discern whether it was the exposure to morally injurious events, or the expression of distress associated with MI that contributed to the findings. Future work should ensure that exposure to morally injurious events and the expression of distress associated with MI are clearly delineated. Another weakness of the study is that guilt and shame are indirectly assessed via PTSD cluster D criteria; future studies may address this weakness by including measures of guilt and shame to directly test these relations. Collectively, these limitations also affect the representativeness of the significant findings, and it is cautioned that these findings are preliminary in nature. Subsequently, future work should endeavor to replicate these findings.
An additional avenue for future work is the further exploration of the relation between perceived betrayals and PTSD symptoms. As discussed previously, in the context of the COVID-19 pandemic, military personnel and Veterans have been called on to assist front-line health care workers in long-term-care facilities where they have witnessed patients in deplorable conditions.20,21 Notably, not only have military personnel witnessed and experienced these events, but so too did front-line health care workers. Although these two groups are marked by significant differences, including their training, work environments (e.g., health care settings vs. battle theatres), and organizational structures, the betrayal of the central dictums of care alongside the betrayals and failures of the health care system and government to protect patients and front-line health care workers may subsequently expose both groups to potentially morally injurious events and their subsequent consequences.40 Future work should consider exploring these potential associations and differences among military personnel, Veterans, and front-line health care workers in the wake of the COVID-19 pandemic. Finally, much future work is needed to elucidate whether targeting difficulties with emotion regulation will improve military personnel’s and Veterans’ psychological distress after exposure to morally injurious experiences.
Despite the study’s limitations and preliminary findings, it serves as an initial step in considering additional risk factors associated with MI among military personnel and Veterans, and it postulates whether other populations, such as front-line health care workers, may be considered as also experiencing potentially morally injurious events. Accordingly, this lays the foundation for future research regarding MI and subsequently improving overall social and occupational functioning.
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Alina Protopopescu helped select the research questions, conducted the literature search, analyzed the results, and draft ed the manuscript. Margaret C. McKinnon, Ruth A. Lanius, and Rakesh Jetly, conceived the research and assisted in the interpretation of study data. All authors revised the manuscript for important intellectual content and approved the final version submitted for publication.
The study protocol was approved by Homewood Health Centre Research Ethics Board, Homewood Health Centre, Guelph, Ontario, Canada.
Informed consent was collected from all participants in the prospective data collection portion of the study.