Patterns of Distress in the Context of Moral Stressors: Validity of the Moral Injury Construct and its Association with PTSD and Depression within and Outside the Military Context
Creators: name: Houle, Stephanie
Publisher: name: Université d'Ottawa / University of Ottawa
Year: 2023
Subjects: moral injury
depression
PTSD
military
COVID-19
stress
moral appraisals
clinical psychology
mental health
nosology

description: Moral injury (MI) is a term that is increasingly being used to describe the psycho-spiritual consequences of events that deeply transgress an individual’s core human values. Stemming most predominantly from the literature on military mental health, MI is understood to be characterized by intense moral emotions such as guilt, shame and anger, as well as existential and spiritual conflict prompted by an event that has deeply disrupted an individual’s beliefs about themselves and the world. Emerging research has shown that exposure to such events as well as particular features of MI distress are associated with increased incidence and severity of mental health problems, such as PTSD and depression. To date, the majority of the research on MI has been conducted in the military context, most predominantly in the United States. Thus, the two studies included in this dissertation come together to evaluate the construct validity of MI by assessing whether a) the patterns of distress identified in military populations to date could also be observed in the Canadian military context, and b) the patterns of distress most pertinent to MI thus identified in the occupational stress literature could be observed in the general population in the context of the COVID-19 pandemic. In Study 1, treatment-seeking military members and Veterans (n = 18) completed a semi-structured interview about the impact of military experiences that deeply disrupted their core beliefs and values. A qualitative analysis was performed and yielded eight main themes: change in moral attitude, increased sensitivity and reactivity to moral situations, loss of trust, disruptions in identity, disruptions in spirituality, disruptions in interpersonal relatedness, rumination, and internalizing and externalizing emotions and behaviours. In addition to the participants who completed the interview, an additional 37 participants (n = 55) completed a structured diagnostic interview and self-report measures of exposure to potentially morally injurious events (PMIEs), combat exposure, guilt, anger, posttraumatic stress disorder (PTSD) and depression. Quantitative analyses revealed that PMIE exposure, but not combat exposure, was related to psychological distress, most notably to symptoms of PTSD. In Study 2, participants recruited from the general population (n = 355) completed an online survey assessing a) exposure to and appraisals of morally-laden COVID-19 stressors, b) mental health symptoms, and c) dispositional characteristics including trait emotions, anxiety sensitivity, sense of duty, and religiosity/spirituality. Path analysis revealed specific indirect associations between self-based moral appraisals and PTSD and depression through guilt, and between both self- and other-based moral appraisals and PTSD and depression through anger. Number of COVID-19 stressors had no influence on these associations. Sense of duty, reparative guilt, and anxiety sensitivity best predicted negative moral appraisals. Together, findings from these studies provide support for the MI construct and extend existing findings by showing that the associations among key features of MI and mental health can be observed in various contexts, and that patterns of distress theorized to comprise the MI construct likely extend to lower-level stressors outside the military context. Potential mechanisms regarding the etiology and maintenance of psychological distress in the context of MI were also identified (e.g., moral appraisals and cognitive features such as rumination), which require further investigation. A better understanding of MI across contexts is likely to help refine approaches to clinical case conceptualization and treatment for those at risk of mental health problems in the aftermath of morally distressing events.