Examining the associations among moral injury, difficulties with emotion regulation, and symptoms of PTSD, depression, anxiety, and stress among Canadian military members and Veterans: A preliminary study

INTRODUCTION

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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.

RESULTS

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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 (r_s = 0.3, p = 0.03; Table 2) and MI and alterations in cognition and mood symptoms related to PTSD (r_s = 0.2, p = 0.04). Perceived betrayals also correlated significantly with alterations in cognition and mood symptoms (r_s = 0.3, p = 0.02). No significant correlations were found among MI, perceived transgressions, and perceived betrayals with PTSD symptom severity (r_s = 0.2, p = 0.06; r_s = 0.2, p = 0.1; and r_s = 0.2, p = 0.06, respectively), depression (r_s = 0.2, p = 0.08; r_s = 0.2, p = 0.1; and r_s = 0.2, p = 0.1, respectively), anxiety (r_s = 0.1, p = 0.3; r_s = 0.1, p = 0.2; and r_s = 0.03, p = 0.8, respectively), or stress (r_s = 0.1, p = 0.2; r_s = 0.09, p = 0.4; and r_s = 0.2, p = 0.1, respectively) symptoms. Perceived transgressions and perceived betrayals were not significantly associated with difficulties with emotion regulation (r_s = 0.2, p = 0.1, and r_s = 0.2, p = 0.1, respectively). MI and difficulties with emotion regulation approached significance, but did not reach the α threshold (i.e., r_s = 0.2, p = 0.07).

PTSD symptom severity correlated significantly with depression (r_s = 0.6, p < 0.001), anxiety (r_s = 0.6, p < 0.001), and stress (r_s = 0.6, p < 0.001) symptoms. Difficulties with emotion regulation were also correlated significantly with PTSD (r_s = 0.6, p < 0.001), depression (r_s = 0.7, p < 0.001), anxiety (r_s = 0.6, p < 0.001), and stress (r_s = 0.7, p < 0.001) symptoms.

DISCUSSION

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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)}

Table 2. Summary of Spearman’s rs (controlling for age and sex) for MIES, PCL-5, DASS-21, and DERS sub-scales and total scores

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.

The authors have nothing to disclose.

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.

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None declared.

This manuscript has been peer reviewed.