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Faigenbloom D, Zerach G, Levi-Belz Y. Moral Injury and Its Consequences Among Combat Veterans: Preliminary Findings on the Role of Moral Judgment. JOURNAL OF INTERPERSONAL VIOLENCE 2024:8862605241265425. [PMID: 39126251 DOI: 10.1177/08862605241265425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2024]
Abstract
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.
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Affiliation(s)
- Dor Faigenbloom
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
| | - Gadi Zerach
- Department of Psychology, Ariel University, Israel
| | - Yossi Levi-Belz
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
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Wetzler EL, Erbe RG, Cornwell JFM, Wood MD. Dispositional mindfulness moderates the links between potentially morally injurious event exposure and symptoms of anxiety and depression but not suicidal ideation. J Trauma Stress 2024; 37:574-585. [PMID: 38548620 DOI: 10.1002/jts.23032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 01/24/2024] [Accepted: 02/15/2024] [Indexed: 08/02/2024]
Abstract
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.
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Affiliation(s)
- Elizabeth L Wetzler
- United States Military Academy, Department of Behavioral Sciences and Leadership, West Point, New York, USA
| | - Ryan G Erbe
- United States Military Academy, Simon Center for the Professional Military Ethic, West Point, New York, USA
| | - James F M Cornwell
- Wheaton College, School of Psychology, Counseling, and Family Therapy, Wheaton, Illinois, USA
| | - Michael D Wood
- United States Military Academy, Department of Behavioral Sciences and Leadership, West Point, New York, USA
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Levinstein Y, Zerach G, Levi-Belz Y, Bonanno GA. Trajectories of moral injury and their associations with posttraumatic stress symptoms among recently discharged israeli veterans. J Psychiatr Res 2024; 177:321-329. [PMID: 39067256 DOI: 10.1016/j.jpsychires.2024.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/15/2024] [Accepted: 07/15/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND While it is already known that potentially morally injurious events (PMIEs) have a deleterious effect on veterans, little is known about the changes in PMIEs subjective appraisals over time, as well as its contribution to changes in psychiatric symptoms. In the current study, we longitudinally assessed subjective appraisals of PMIEs experienced during combat military service and their associations with posttraumatic stress symptoms (PTSS) among recently discharged combat veterans. METHOD Participants were 374 veterans who participated in a one-year longitudinal study with three measurement points: T1-one month before discharge from army service, and then again six months and twelve months following discharge (T2 and T3, respectively). RESULTS Latent Growth Mixture Modeling (LGMM) indicated heterogenic patterns of changes in PMIEs across measurements. The 'resilient' (low and stable PMIEs) trajectory best represented PMIE, followed by 'recovery' and 'chronic' fluctuating trajectories. Moreover, the 'resilient' PMIEs trajectory was found to be consistently associated with lower PTSS scores compared to 'chronic' or 'worsening' trajectories. CONCLUSIONS Our findings are the first to identify longitudinal trajectories of PMIEs subjective appraisals and to provide evidence of their association with PTSS, which might serve as potential assessment and intervention targets among recently discharged traumatized veterans.
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Affiliation(s)
- Yoav Levinstein
- Dept. of Health and Well-being, Medical Corps, IDF, School of Social Work, Bar-Ilan University, Ramat-Gan, Israel.
| | - Gadi Zerach
- Dept. of Psychology, Ariel University, Ariel, Israel
| | - Yossi Levi-Belz
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
| | - George A Bonanno
- Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY, USA
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McDaniel JT, Redner R, Haun JN, McCowen P, Higgins ST. Moral injury among women military veterans and demand for cigarettes: A behavioral economic investigation using a hypothetical purchase task. Prev Med 2024:108036. [PMID: 38852890 DOI: 10.1016/j.ypmed.2024.108036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/20/2024] [Accepted: 06/06/2024] [Indexed: 06/11/2024]
Abstract
OBJECTIVES Unlike the United States general population, veteran women - as opposed to veteran men - have greater smoking prevalence; yet, little is known regarding factors that influence smoking in veteran women. The purpose of this study was to begin examining the relationship between a psychological concept known as moral injury and demand for cigarettes among veteran women. METHODS Veteran women who smoke (n = 44) were recruited for this cross-sectional study from Amazon MTurk, Reddit, and a veteran-serving non-profit organization in June-July 2023. Consenting participants received $2 for completing the cigarette purchase task (CPT), Fagerstrom Test for Nicotine Dependence (FTND), and the military version of the Moral Injury Symptom Scale (MISS-M-SF). We examined five CPT demand indices and calculated a modified exponential demand model stratified by moral injury severity status (i.e., probable vs. unlikely). RESULTS Probable morally injured women exhibited significantly higher relative reinforcing value (RRV) for smoking than unlikely morally injured women (F1, 920 = 9.16, p = 0.003). Average cigarette consumption at $0 (i.e., Q0) was 48.56% higher (M = 22.24 vs. M = 13.55) in probable compared to unlikely morally injured women (p = 0.04, Hedge's g = 0.74). FTND scores were significantly correlated with Pmax (i.e., demand elasticity point) and Omax (i.e., maximum expenditure) values in both populations (rs = 0.42-0.68, ps < 0.05). CONCLUSIONS We provide preliminary evidence of the relatively high RRV of smoking in morally injured veteran women. Continued research is needed to refine the characterization of this relationship.
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Affiliation(s)
- Justin T McDaniel
- School of Human Sciences, Southern Illinois University, 475 Clocktower Drive, Carbondale, IL 62901, USA.
| | - Ryan Redner
- School of Psychological and Behavioral Sciences, Southern Illinois University, 1125 Lincoln Drive, Carbondale, IL 62901, USA.
| | - Jolie N Haun
- James A. Haley Veterans' Hospital, Veterans Health Administration, 13000 Bruce B Downs Blvd., Tampa, FL 33612, USA.
| | - Patrick McCowen
- School of Human Sciences, Southern Illinois University, 475 Clocktower Drive, Carbondale, IL 62901, USA.
| | - Stephen T Higgins
- Departments of Psychiatry and Psychological Science, University of Vermont, 1 South Prospect Street, OH3, MS482, Burlington, VT 05401, USA.
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Campbell BM, Knipp MA, Anwar SS, Hoopsick RA. Moral injury and substance use among United States healthcare workers. Stress Health 2024; 40:e3321. [PMID: 37786303 DOI: 10.1002/smi.3321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/08/2023] [Accepted: 09/18/2023] [Indexed: 10/04/2023]
Abstract
Moral injury (i.e., perpetrating, witnessing, failing to prevent, or being a victim of acts that transgress one's moral beliefs, values, or ethics) has largely been studied in military-connected populations and is associated with a range of adverse psychological sequelae. Emerging literature suggests that healthcare workers also experience moral injury, particularly in the context of the ongoing COVID-19 pandemic. However, it is not known if moral injury contributes to substance use among healthcare workers or whether these effects might differ by gender, race/ethnicity, or occupational level. In March 2022, we collected self-reported pilot data from a diverse sample of US healthcare workers (N = 200) We examined the cross-sectional relationships between moral injury and several measures of substance use (i.e., current non-medical use of prescription drugs [NMUPD], current cannabis use, current use of other illicit drugs, and hazardous drinking) using separate logistic regression models. Next, we used separate interaction models to examine if any of these relations differed by gender, race/ethnicity, or occupational level. In main effects models, healthcare workers reporting greater moral injury had greater odds of current NMUPD (adjusted odds ratio (aOR) = 1.07; p < 0.001), current use of other illicit drugs (aOR = 1.09; p < 0.01), and hazardous drinking (aOR = 1.07; p < 0.01). These relations did not differ by race/ethnicity or occupational level (ps > 0.05); however, men were more likely to report current NMUPD and hazardous drinking (ps < 0.05) in the presence of high moral injury than women healthcare workers. Our findings suggest that healthcare workers experience substantial distress related to morally injurious events, which may affect their likelihood of NMUPD, cannabis use, use of other illicit drugs, and hazardous drinking, and that men in healthcare may be particularly at risk. Healthcare organizations should address systemic issues driving moral injury (e.g., resource shortages, lack of psychosocial support) to prevent substance-related harms among healthcare workers.
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Affiliation(s)
- Benjamin M Campbell
- Department of Kinesiology and Community Health, University of Illinois Urbana-Champaign, Champaign, Illinois, USA
| | - Michael A Knipp
- Department of Kinesiology and Community Health, University of Illinois Urbana-Champaign, Champaign, Illinois, USA
| | - Sinan S Anwar
- Department of Kinesiology and Community Health, University of Illinois Urbana-Champaign, Champaign, Illinois, USA
| | - Rachel A Hoopsick
- Department of Kinesiology and Community Health, University of Illinois Urbana-Champaign, Champaign, Illinois, USA
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Houle SA, Ashbaugh AR. Predictors of negative moral appraisals and their association with symptoms of post-traumatic stress and depression in the context of COVID-19 related stressors. Stress Health 2024; 40:e3296. [PMID: 37526521 DOI: 10.1002/smi.3296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 05/17/2023] [Accepted: 07/10/2023] [Indexed: 08/02/2023]
Abstract
Research on moral injury (MI) suggests that negative moral appraisals of stressful events can impact mental health in high-stakes occupational contexts (e.g., military). Few studies have examined these associations in the general population, limiting the generalisability of findings. Furthermore, factors that may predispose an individual to adverse outcomes in the context of moral stressors remain largely unknown. The objectives of this study were to (1) explore the applicability of the MI construct to stressors experienced by the general public during the COVID-19 pandemic; (2) explore how trait differences in sense of duty, religiosity/spirituality, anxiety sensitivity, and guilt, shame, and anger, predict negative moral appraisals of COVID-19 stressors. Participants (n = 355) completed an online survey assessing exposure to and appraisals of COVID-19 stressors, mental health symptoms, and dispositional characteristics (i.e., trait emotions, anxiety sensitivity, sense of duty, religiosity/spirituality). Path analysis revealed specific indirect associations between self-based moral appraisals and posttraumatic stress disorder (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 associations. Sense of duty, reparative guilt, and anxiety sensitivity best predicted negative moral appraisals. Findings partially support the applicability of the MI construct outside the occupational context.
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Webb EL, Ireland JL, Lewis M, Morris D. Potential Sources of Moral Injury for Healthcare Workers in Forensic and Psychiatric Settings: A Systematic Review and Meta-ethnography. TRAUMA, VIOLENCE & ABUSE 2024; 25:918-934. [PMID: 37083056 PMCID: PMC10913356 DOI: 10.1177/15248380231167390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
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.
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Affiliation(s)
- Elanor Lucy Webb
- Centre for Developmental and Complex Trauma, St Andrew’s Healthcare, Northampton, UK
| | - Jane L. Ireland
- University of Central Lancashire, Preston, UK
- Ashworth Research Centre, Mersey Care NHS Foundation Trust, Liverpool, UK
| | - Michael Lewis
- University of Central Lancashire, Preston, UK
- Ashworth Research Centre, Mersey Care NHS Foundation Trust, Liverpool, UK
| | - Deborah Morris
- Centre for Developmental and Complex Trauma, St Andrew’s Healthcare, Northampton, UK
- University of Buckingham, UK
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Nichter B, Hill ML, Maguen S, Norman SB, Fischer IC, Pietrzak RH. Health and psychiatric impairment associated with moral injury, military sexual trauma, and their co-occurrence in U.S. combat veterans. J Psychosom Res 2024; 179:111617. [PMID: 38394711 DOI: 10.1016/j.jpsychores.2024.111617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 01/16/2024] [Accepted: 02/17/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Military 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. METHOD Cross-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. RESULTS The 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. CONCLUSIONS The 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.
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Affiliation(s)
- Brandon Nichter
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America.
| | - Melanie L Hill
- Department of Psychiatry, University of California San Diego, La Jolla, CA, United States of America
| | - Shira Maguen
- San Francisco VA Health Care System, San Francisco, CA, United States of America; University of California - San Francisco, San Francisco, United States of America
| | - Sonya B Norman
- Department of Psychiatry, University of California San Diego, La Jolla, CA, United States of America; VA San Diego Healthcare System, San Diego, CA, USA; National Center for PTSD, White River Junction, VT, United States of America
| | - Ian C Fischer
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America; National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Robert H Pietrzak
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America; National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA; Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, United States of America
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Houle SA, Ein N, Gervasio J, Plouffe RA, Litz BT, Carleton RN, Hansen KT, Liu JJW, Ashbaugh AR, Callaghan W, Thompson MM, Easterbrook B, Smith-MacDonald L, Rodrigues S, Bélanger SAH, Bright K, Lanius RA, Baker C, Younger W, Bremault-Phillips S, Hosseiny F, Richardson JD, Nazarov A. Measuring moral distress and moral injury: A systematic review and content analysis of existing scales. Clin Psychol Rev 2024; 108:102377. [PMID: 38218124 DOI: 10.1016/j.cpr.2023.102377] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/03/2023] [Accepted: 12/21/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Moral distress (MD) and moral injury (MI) are related constructs describing the negative consequences of morally challenging stressors. Despite growing support for the clinical relevance of these constructs, ongoing challenges regarding measurement quality risk limiting research and clinical advances. This study summarizes the nature, quality, and utility of existing MD and MI scales, and provides recommendations for future use. METHOD We identified psychometric studies describing the development or validation of MD or MI scales and extracted information on methodological and psychometric qualities. Content analyses identified specific outcomes measured by each scale. RESULTS We reviewed 77 studies representing 42 unique scales. The quality of psychometric approaches varied greatly across studies, and most failed to examine convergent and divergent validity. Content analyses indicated most scales measure exposures to potential moral stressors and outcomes together, with relatively few measuring only exposures (n = 3) or outcomes (n = 7). Scales using the term MD typically assess general distress. Scales using the term MI typically assess several specific outcomes. CONCLUSIONS Results show how the terms MD and MI are applied in research. Several scales were identified as appropriate for research and clinical use. Recommendations for the application, development, and validation of MD and MI scales are provided.
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Affiliation(s)
- Stephanie A Houle
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Research Directorate, Veterans Affairs Canada, Charlottetown, Canada
| | - Natalie Ein
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychiatry, Western University, London, Canada
| | - Julia Gervasio
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada
| | - Rachel A Plouffe
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychology, University of Dundee, Dundee, UK
| | - Brett T Litz
- Department of Psychiatry, Boston University, Boston, USA; Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, USA; Department of Psychological and Brain Sciences, Boston University, Boston, USA
| | | | - Kevin T Hansen
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada
| | - Jenny J W Liu
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychiatry, Western University, London, Canada
| | | | - Walter Callaghan
- Department of Anthropology, University of Toronto, Toronto, Canada
| | | | - Bethany Easterbrook
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychology, Neuroscience & Behaviour, McMaster University, Hamilton, Canada
| | | | - Sara Rodrigues
- The Atlas Institute for Veterans and Families, Ottawa, Canada
| | | | | | - Ruth A Lanius
- Department of Psychiatry, Western University, London, Canada
| | - Clara Baker
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada
| | - William Younger
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada
| | | | | | - J Don Richardson
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychiatry, Western University, London, Canada; St. Joseph's Operational Stress Injury Clinic, St. Joseph's Health Care London, London, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
| | - Anthony Nazarov
- MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, Canada; Department of Psychiatry, Western University, London, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada.
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10
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Boska RL, Bishop TM, Capron DW, Paxton Willing MM, Ashrafioun L. Difficulties with emotion regulation within PTSD clusters and moral injury subtypes. MILITARY PSYCHOLOGY 2024:1-9. [PMID: 38421375 DOI: 10.1080/08995605.2024.2322904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 02/12/2024] [Indexed: 03/02/2024]
Abstract
Treatment and research centered on trauma-related mental health issues have largely focused on posttraumatic stress disorder (PTSD); however, moral injury is another important mental health concern requiring attention. There is a paucity of research examining how PTSD and moral injury affect emotion regulation. The current investigation examined how PTSD clusters and moral injury subtypes were uniquely associated with difficulties with emotion regulation. Participants consisted of 253 previously deployed military personnel who were recruited online. To be included in the study, participants had to verify that they had served in the U.S. Military, had been deployed as part of their military service, and endorsed elevated levels of symptoms associated with PTSD and/or moral injury. A hierarchical linear regression was conducted to examine the association between PTSD symptom clusters, moral injury subtypes, and difficulties with emotion regulation. Results indicated that alterations in arousal and reactivity was the only PTSD symptom cluster associated with difficulties with emotion regulation. Self-transgressions was the only facet of moral injury significantly associated with difficulties with emotion regulation. This is the first study to examine the association between emotion dysregulation, PTSD symptom clusters, and moral injury in previously deployed U.S. Military.
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Affiliation(s)
- Rachel L Boska
- The War Related Illness and Injury Study Center, The VA New Jersey Healthcare System, East Orange, New Jersey
- VA Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, Canandaigua, New York
| | - Todd M Bishop
- VA Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, Canandaigua, New York
- Department of Psychiatry, University of Rochester School of Medicine & Dentistry, Rochester, New York
| | - Daniel W Capron
- Department of Psychology, Louisiana State University, Baton Rouge, Louisiana
| | - Maegan M Paxton Willing
- Center for Deployment Psychology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland
| | - Lisham Ashrafioun
- VA Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, Canandaigua, New York
- Department of Psychiatry, University of Rochester School of Medicine & Dentistry, Rochester, New York
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11
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Brennan CJ, Roberts C, Cole JC. Prevalence of occupational moral injury and post-traumatic embitterment disorder: a systematic review and meta-analysis. BMJ Open 2024; 14:e071776. [PMID: 38382965 PMCID: PMC10882372 DOI: 10.1136/bmjopen-2023-071776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024] Open
Abstract
OBJECTIVES Occupational moral injury and post-traumatic embitterment disorder (PTED) describe the psychological distress caused by exposure to injustice at work. This meta-analysis aims to determine the prevalence of occupational moral injury and PTED and establish whether prevalence estimates differ depending on occupation. DESIGN A systematic review and meta-analysis. DATA SOURCES Google Scholar, PubMed, APA PsycINFO, Web of Science Core Collection, Scopus, ScienceDirect and Sage Journals Online were searched in June 2020 and updated in November 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Observational studies that measured prevalence or average scores of moral injury, or PTED in any occupational group and any geographical location. DATA EXTRACTION AND SYNTHESIS Two independent reviewers screened and coded eligible studies. Study design, participant demographics, sampling method, location, measurement tool and prevalence or average scores were extracted. Risk of bias was assessed using the Quality Assessment Checklist for Prevalence Studies tool. Meta-analysis was conducted using random effects models. Results that could not be combined were summarised qualitatively in a narrative synthesis using the Guidance for Systematic Reviews. RESULTS In total, 88 studies across armed forces and veterans, healthcare, first responders, educators, journalists, child protection service employees, the unemployed, public-sector employees and mixed occupations were included. Studies included in each separate meta-analysis based on the measure used ranged from 2 to 30. The pooled prevalence of clinically relevant moral injury in healthcare professionals was 45%, and exposure to any potentially morally injurious event (PMIE) across occupations was 67%. Exposure to transgressions by others and betrayal was significantly lower in the armed forces than civilian occupations. Pooled prevalence of PTED across occupations was 26%. CONCLUSION Exposure to PMIEs, moral injury symptoms and PTED are prevalent at work and exposure to transgressions by others and betrayal are more likely in civilian occupations than the armed forces. PROSPERO REGISTRATION NUMBER CRD42020191766.
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Affiliation(s)
| | - Carl Roberts
- Psychology, University of Liverpool, Liverpool, UK
| | - Jon C Cole
- Psychology, University of Liverpool, Liverpool, UK
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12
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Levi-Belz Y, Ben-Yehuda A, Levinstein Y, Zerach G. Moral injury and pre-deployment personality factors as contributors to psychiatric symptomatology among combatants: a two-year prospective study. Eur J Psychotraumatol 2024; 15:2312773. [PMID: 38334135 PMCID: PMC10860427 DOI: 10.1080/20008066.2024.2312773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 01/13/2024] [Indexed: 02/10/2024] Open
Abstract
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.
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Affiliation(s)
- Yossi Levi-Belz
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
| | - Ariel Ben-Yehuda
- Department of Health and Well-being, Medical Corps, IDF, Israel
- Shalvata Mental Health Center, Clalit Health Services, Hod Hasharon, Israel
| | - Yoav Levinstein
- Shalvata Mental Health Center, Clalit Health Services, Hod Hasharon, Israel
- School of Social Work, Bar-Ilan University, Ramat-Gan, Israel
| | - Gadi Zerach
- Department of Psychology, Ariel University, Ariel, Israel
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Coimbra BM, Zylberstajn C, van Zuiden M, Hoeboer CM, Mello AF, Mello MF, Olff M. Moral injury and mental health among health-care workers during the COVID-19 pandemic: meta-analysis. Eur J Psychotraumatol 2024; 15:2299659. [PMID: 38189775 PMCID: PMC10776063 DOI: 10.1080/20008066.2023.2299659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/11/2023] [Indexed: 01/09/2024] Open
Abstract
Background: During the COVID-19 pandemic, health-care workers (HCWs) may have been confronted with situations that may culminate in moral injury (MI). MI is the psychological distress that may result from perpetrating or witnessing actions that violate one's moral codes. Literature suggests that MI can be associated with mental health problems.Objective: We aimed to meta-analytically review the literature to investigate whether MI is associated with symptoms of posttraumatic stress disorder (PTSD), anxiety, depression, burnout, and suicidal ideation among active HCWs during the COVID-19 pandemic.Method: We searched eight databases for studies conducted after the onset of the COVID-19 pandemic up to 18 July 2023, and performed random-effects meta-analyses to examine the relationship between MI and various mental health outcomes.Results: We retrieved 33 studies from 13 countries, representing 31,849 individuals, and pooled 79 effect sizes. We found a positive association between MI and all investigated mental health problems (rs = .30-.41, all ps < .0001). Between-studies heterogeneity was significant. A higher percentage of nurses in the samples was associated with a stronger relationship between MI and depressive and anxiety symptoms. Samples with a higher percentage of HCWs providing direct care to patients with COVID-19 exhibited a smaller effect between MI and depressive and anxiety symptoms. We observed a stronger effect between MI and PTSD symptoms in US samples compared to non-US samples.Conclusion: We found that higher MI is moderately associated with symptoms of PTSD, anxiety, depression, burnout, and suicidal ideation among HCWs during the COVID-19 pandemic. Our findings carry limitations due to the array of MI scales employed, several of which were not specifically designed for HCWs, but underscore the need to mitigate the effect of potentially morally injurious events on the mental health of HCWs.
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Affiliation(s)
- Bruno Messina Coimbra
- Programme for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
- Department of Methodology and Statistics, Faculty of Social and Behavioral Sciences, Utrecht University, Utrecht, The Netherlands
- Amsterdam UMC, Department of Psychiatry, Amsterdam Public Health Research Institute and Amsterdam Neuroscience Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Cecilia Zylberstajn
- Programme for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Mirjam van Zuiden
- Department of Clinical Psychology, Utrecht University, Utrecht, The Netherlands
| | - Chris Maria Hoeboer
- Amsterdam UMC, Department of Psychiatry, Amsterdam Public Health Research Institute and Amsterdam Neuroscience Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Andrea Feijo Mello
- Programme for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Marcelo Feijo Mello
- Programme for Research and Care on Violence and PTSD (PROVE), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Albert Einstein, São Paulo, Brazil
| | - Miranda Olff
- Amsterdam UMC, Department of Psychiatry, Amsterdam Public Health Research Institute and Amsterdam Neuroscience Research Institute, University of Amsterdam, Amsterdam, The Netherlands
- ARQ National Psychotrauma Centre, Diemen, The Netherlands
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Chen R, Gordon M, Chervenak F, Coverdale J. Addressing Moral Distress After Dobbs v. Jackson Women's Health Organization : A Professional Virtues-Based Approach. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2024; 99:12-15. [PMID: 37816216 DOI: 10.1097/acm.0000000000005476] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
ABSTRACT The June 2022 U.S. Supreme Court decision in Dobbs v. Jackson Women's Health Organization abolished federal protections for reproductive choice. In states where subsequent legislation has restricted or banned access to abortion services, physicians and trainees are prevented from providing ethically justified evidence-based care when patients with previable pregnancies are seeking an abortion. Pregnant patients' vulnerabilities, stress, and the undue burden that they experience when prevented from acting in accordance with their reproductive decision-making can evoke negative emotional consequences, including moral distress in clinicians. Moral distress occurs when clinicians feel a moral compulsion to act a certain way but cannot do so because of external constraints, including being hindered by state laws that curtail practicing in line with professional standards on reproductive health care. Moral distress has the potential to subvert prudent clinical judgment. The authors provide recommendations for managing moral distress in these circumstances based on the professional virtues. The fundamental professional virtues of integrity, compassion, self-effacement, self-sacrifice, and humility inform the management of moral distress and how to respond thoughtfully and compassionately, without over-identification or indifference to the plight of patients denied abortions. The authors also discuss the role of academic leaders and medical educators in cultivating a virtue-based professional culture at the forefront of clinical and educational processes in a post- Dobbs world.
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15
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Jamieson N, Carey LB, Jamieson A, Maple M. Examining the Association Between Moral Injury and Suicidal Behavior in Military Populations: A Systematic Review. JOURNAL OF RELIGION AND HEALTH 2023; 62:3904-3925. [PMID: 37592186 DOI: 10.1007/s10943-023-01885-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/25/2023] [Indexed: 08/19/2023]
Abstract
The increasing number of suicides among military populations cannot be fully accounted for by conventional risk factors like Post-Traumatic Stress Disorder (PTSD). As a result, researchers and theorists propose that delving into the concept of Moral Injury could offer a more comprehensive understanding of the phenomenon of suicide. Moral Injury is not currently a recognized mental health disorder but can be associated with PTSD. Moral Injury is a multi-dimensional issue that profoundly affects emotional, psychological, behavioral, social, and spiritual well-being. The objective of this systematic review is to examine the association between Moral Injury and suicidal behavior (suicide ideation, plans and or suicide attempt) within military populations. The review will specifically concentrate on identifying and analyzing studies that have investigated the connection between these variables, with a specific focus on the context of military personnel both serving and former serving members. Of the 2214 articles identified as part of this review, 12 studies satisfied the research criteria with a total participant sample having an average age of 40.7 years. The male population accounted for 78.6% of the overall sample. Two studies were identified as high-quality, while the remaining ten were rated as moderate. The analysis of these twelve studies consistently affirms a connection between Moral Injury and suicidal behavior; most obviously, that exposure to morally injurious events substantially amplify the risk of suicide, with higher levels of potential exposure being linked to increased Moral Injury and heightened levels of suicidal behavior. Our review uncovered noteworthy findings regarding the association between Moral Injury and suicidal behavior, marking a pioneering effort in exploring this association and offering valuable insights into this emerging issue. Several limitations are noted regarding this review and recommendations are made concerning the need to prioritize, expand and employ longitudinal research designs that include non-military populations such as first responders (e.g., police, paramedics, firefighters) and medical, nursing, or allied health professionals-all disciplines known to be impacted by Moral Injury.
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Affiliation(s)
- Nikki Jamieson
- Moral Injury Australia, Brisbane, Queensland, Australia.
| | - Lindsay B Carey
- Palliative Care Unit, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
- Institue of Ethics and Society, The University of Notre Dame, Sydney Campus, New South Wales, Australia
| | | | - Myfanwy Maple
- School of Health, University of New England, Armidale, New South Wales, Australia
- Manna Institute, Faculty of Medicine and Health, University of New England, Armidale, New South Wales, Australia
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16
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McDaniel JT, Redner R, Jayawardene W, Haun J, Clapp J, Che D, Renzaglia K, Abou-Jabal D. Moral Injury is a Risk Factor for Substance Use and Suicidality Among US Military Veterans with and without Traumatic Brain Injury. JOURNAL OF RELIGION AND HEALTH 2023; 62:3926-3941. [PMID: 37679519 DOI: 10.1007/s10943-023-01905-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 09/09/2023]
Abstract
A national survey of United States veterans was conducted, yielding 252 veterans with Traumatic Brain Injury (TBI) and 1235 veterans without TBI. Participants were asked questions about moral injury, suicidality, substance use, and other sociodemographic variables. Multivariable linear regression analysis was used to examine the previously described relationships. Increasing severity of moral injury was associated with higher scores on the substance use tool (b = 0.02, p = 0.04), although the magnitude of effect was not different from those without TBI (Z = - 0.57, p = 0.72). Increasing severity of moral injury was positively associated with suicidal behavior scores (b = 0.10, p < 0.01). The strength of this relationship was stronger in veterans with TBI than those without TBI (Z = 1.78, p = 0.04). Rehabilitation programs that treat veterans for TBI may need to consider the evaluation of moral injury given its association with adverse events in this population.
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Affiliation(s)
- Justin T McDaniel
- School of Human Sciences, Southern Illinois University, 475 Clocktower Drive, Carbondale, IL, 62901, USA.
| | - Ryan Redner
- School of Psychological and Behavioral Sciences, Southern Illinois University, Carbondale, IL, USA
| | | | - Jolie Haun
- James A. Haley Veterans' Hospital, US Veterans Health Administration, Tampa, FL, USA
| | - John Clapp
- School of Social Work, University of Southern California, Los Angeles, CA, USA
| | - Dunren Che
- School of Computing, Southern Illinois University, Carbondale, IL, USA
| | - Karen Renzaglia
- Department of Plant Biology, Southern Illinois University, Carbondale, IL, USA
| | - Dania Abou-Jabal
- School of Human Sciences, Southern Illinois University, Carbondale, IL, USA
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17
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Phelps AJ, Madden K, Carleton RN, Johnson L, Carey LB, Mercier JM, Mellor A, Baills J, Forbes D, Devenish-Meares P, Hosseiny F, Dell L. Towards a Holistic Model of Care for Moral Injury: An Australian and New Zealand Investigation into the Role of Police Chaplains in Supporting Police Members following exposure to Moral Transgression. JOURNAL OF RELIGION AND HEALTH 2023; 62:3995-4015. [PMID: 37697218 PMCID: PMC10682271 DOI: 10.1007/s10943-023-01908-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 09/13/2023]
Abstract
Police members can be exposed to morally transgressive events with potential for lasting psychosocial and spiritual harm. Through interviews with police members and police chaplains across Australia and New Zealand, this qualitative study explores the current role that police chaplains play in supporting members exposed to morally transgressive events. The availability of chaplains across police services and the close alignment between the support they offer, and the support sought by police, indicates they have an important role. However, a holistic approach should also consider organizational factors, the role of leaders, and access to evidence-based treatment in collaboration with mental health practitioners.
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Affiliation(s)
- Andrea J Phelps
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Level 3, 161 Barry Street, Carlton, VIC, 3053, Australia.
| | - Kelsey Madden
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Level 3, 161 Barry Street, Carlton, VIC, 3053, Australia
| | | | - Lucinda Johnson
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Level 3, 161 Barry Street, Carlton, VIC, 3053, Australia
| | - Lindsay B Carey
- School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | | | - Andrew Mellor
- National Police Chaplaincy Group, Brisbane, Queensland, Australia
| | - Jeffrey Baills
- National Police Chaplaincy Group, Brisbane, Queensland, Australia
| | - David Forbes
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Level 3, 161 Barry Street, Carlton, VIC, 3053, Australia
| | | | | | - Lisa Dell
- Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Level 3, 161 Barry Street, Carlton, VIC, 3053, Australia
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18
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Levi-Belz Y, Groweiss Y, Blank C. Moral injury and its mental health consequences among protesters: findings from Israel's civil protest against the government's judicial reform. Eur J Psychotraumatol 2023; 14:2283306. [PMID: 37994789 PMCID: PMC10993812 DOI: 10.1080/20008066.2023.2283306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/02/2023] [Indexed: 11/24/2023] Open
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.
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Affiliation(s)
- Yossi Levi-Belz
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
- Department of Behavioral Sciences, Ruppin Academic Center, Emek Hefer, Israel
| | - Yoav Groweiss
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
| | - Carmel Blank
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
- Department of Behavioral Sciences, Ruppin Academic Center, Emek Hefer, Israel
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Serfioti D, Murphy D, Greenberg N, Williamson V. Professionals' perspectives on relevant approaches to psychological care in moral injury: A qualitative study. J Clin Psychol 2023; 79:2404-2421. [PMID: 37310171 DOI: 10.1002/jclp.23556] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 04/12/2023] [Accepted: 05/31/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Despite the increasing consensus that moral injury (MI) is a unique type of psychological stressor, there is an ongoing debate about best practices for psychological care. This qualitative study explored the perceptions of UK and US professionals in the field of MI investigating advances and challenges in treatment or support delivery and issues relating to treatment/support feasibility and acceptability. METHODS 15 professionals were recruited. Semi-structured, telephone/online interviews were carried out, and transcripts were analyzed using thematic analysis. RESULTS Two interconnected themes emerged: perceived barriers to appropriate care for MI cases and recommendations for providing effective care to MI patients. Professionals highlighted the challenges that occur due to the lack of empirical experience with MI, the negligence of patients' unique individual needs and the inflexibility in existing manualised treatments. CONCLUSIONS These findings illustrate the need to evaluate the effectiveness of current approaches and explore alternative pathways, which will effectively support MI patients in the long-term. Key recommendations include the use of therapeutic techniques which lead to a personalised and flexible support plan to meet patients' needs, increase self-compassion and encourage patients to reconnect with their social networks. Interdisciplinary collaborations (e.g., religious/spiritual figures), could be a valuable addition following patients' agreement.
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Affiliation(s)
- Danai Serfioti
- Department of Psychology, School of Social Sciences, Nottingham Trent University, Nottingham, UK
| | - Dominic Murphy
- Department of Psychological Medicine, King's Centre for Military Health Research, King's College London, London, UK
- Research Department, Combat Stress, Surrey, UK
| | - Neil Greenberg
- Department of Psychological Medicine, King's Centre for Military Health Research, King's College London, London, UK
| | - Victoria Williamson
- Department of Psychological Medicine, King's Centre for Military Health Research, King's College London, London, UK
- Department of Experimental Psychology, Anna Watts Building, University of Oxford, Oxford, UK
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D’Alessandro-Lowe AM, Karram M, Ritchie K, Brown A, Millman H, Sullo E, Xue Y, Pichtikova M, Schielke H, Malain A, O’Connor C, Lanius R, McCabe RE, McKinnon MC. Coping, Supports and Moral Injury: Spiritual Well-Being and Organizational Support Are Associated with Reduced Moral Injury in Canadian Healthcare Providers during the COVID-19 Pandemic. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6812. [PMID: 37835082 PMCID: PMC10572244 DOI: 10.3390/ijerph20196812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/08/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023]
Abstract
Healthcare providers (HCPs) have described the onset of shame- and trust-violation-related moral injuries (MI) throughout the COVID-19 pandemic. Previous research suggests that HCPs may turn to various coping methods and supports, such as spirituality/religiosity, substance use, friends/family or organizational support, to manage workplace stress. It remains unknown, however, if similar coping methods and supports are associated with MI among this population. We explored associations between MI (including the shame and trust-violation presentations individually) and coping methods and supports. Canadian HCPs completed an online survey about their mental health and experiences during the COVID-19 pandemic, including demographic indices (e.g., sex, age, mental health history) and measures of MI, organizational support, social support, spiritual well-being, self-compassion, alcohol use, cannabis use and childhood adversity. Three hierarchical multiple linear regressions were conducted to assess the associations between coping methods/supports and (i) MI, (ii) shame-related MI and (iii) trust-violation-related MI, when controlling for age, mental health history and childhood adversity. One hundred and seventy-six (N = 176) HCPs were included in the data analysis. Spiritual well-being and organizational support were each significantly associated with reduced total MI (p's < 0.001), shame-related MI (p = 0.03 and p = 0.02, respectively) and trust-violation-related MI (p's < 0.001). Notably, comparison of the standardized beta coefficients suggests that the association between trust-violation-related MI and both spiritual well-being and organizational support was more than twice as great as the associations between these variables and shame-related MI, emphasizing the importance of these supports and the trust-violation outcomes particularly. Mental health history (p = 0.02) and self-compassion (p = 0.01) were additionally related to shame-related MI only. Our findings indicate that heightened levels of spiritual well-being and organizational support were associated with reduced MI among HCPs during the COVID-19 pandemic. Rather than placing sole responsibility for mental health outcomes on HCPs individually, organizations can instead play a significant role in mitigating MI among staff by implementing evidence-informed organizational policies and interventions and by considering how supports for spiritual well-being may be implemented into existing models of care where relevant for employees.
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Affiliation(s)
- Andrea M. D’Alessandro-Lowe
- Department of Psychology Neuroscience and Behaviour, McMaster University, Hamilton, ON L8S 4L6, Canada;
- Homewood Research Institute, Guelph, ON N13 6K9, Canada
| | - Mauda Karram
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada
| | - Kim Ritchie
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada
- Trent/Fleming School of Nursing, Trent University, Peterborough, ON K9L 0G2, Canada
| | - Andrea Brown
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada
| | - Heather Millman
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada
| | - Emily Sullo
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada
| | - Yuanxin Xue
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada
- Temetry Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Mina Pichtikova
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada
- Department of Applied Psychology and Human Development, University of Toronto, Toronto, ON M5S 1V6, Canada
| | | | - Ann Malain
- Homewood Health Centre, Guelph, ON NIE 6K9, Canada
| | | | - Ruth Lanius
- Homewood Research Institute, Guelph, ON N13 6K9, Canada
- Lawson Health Research Institute, University of Western Ontario, London, ON N6C 2R5, Canada
| | - Randi E. McCabe
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada
- St. Joseph’s Healthcare Hamilton, Hamilton, ON L8N 4A6, Canada
| | - Margaret C. McKinnon
- Homewood Research Institute, Guelph, ON N13 6K9, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L9C 0E3, Canada
- St. Joseph’s Healthcare Hamilton, Hamilton, ON L8N 4A6, Canada
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21
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Fatima M, Imran N, Aamer I, Iqtadar S, Shabbir B. When healers get wounded! Moral injury in healthcare providers during the COVID-19 pandemic in Pakistan. Front Psychiatry 2023; 14:1244055. [PMID: 37795516 PMCID: PMC10545959 DOI: 10.3389/fpsyt.2023.1244055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/06/2023] [Indexed: 10/06/2023] Open
Abstract
Introduction 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. Materials and methods 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. Results 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. Conclusion 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.
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Affiliation(s)
- Madah Fatima
- Academic Department of Psychiatry and Behavioral Sciences, Mayo Hospital, King Edward Medical University, Lahore, Pakistan
| | - Nazish Imran
- Child and Family Psychiatry Department, Mayo Hospital, King Edward Medical University, Lahore, Pakistan
| | - Irum Aamer
- Academic Department of Psychiatry and Behavioral Sciences, Mayo Hospital, King Edward Medical University, Lahore, Pakistan
| | - Somia Iqtadar
- Department of Medicine, Mayo Hospital, King Edward Medical University, Lahore, Pakistan
| | - Bilquis Shabbir
- Department of Medicine, Sir Ganga Ram Hospital, Fatima Jinnah Medical University, Lahore, Pakistan
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Zerach G, Levinstein Y, Levi-Belz Y. Longitudinal associations between transgressions of moral beliefs and suicidal ideation among recently discharged veterans. Psychiatry Res 2023; 327:115392. [PMID: 37536145 DOI: 10.1016/j.psychres.2023.115392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 07/27/2023] [Accepted: 07/29/2023] [Indexed: 08/05/2023]
Abstract
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.
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Affiliation(s)
- Gadi Zerach
- Dept. of Psychology, Ariel University, Ariel, Israel.
| | - Yoav Levinstein
- Dept. of Health and Well-being, Medical Corps, IDF, Israel; School of Social Work, Bar-Ilan University, Ramat-Gan, Israel
| | - Yossi Levi-Belz
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
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Russell B, Mussap AJ. Rumination and threat-biased interpretation mediate posttraumatic stress and growth responses to military stressors. MILITARY PSYCHOLOGY 2023; 35:451-466. [PMID: 37615560 PMCID: PMC10453989 DOI: 10.1080/08995605.2022.2127618] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/14/2022] [Indexed: 10/14/2022]
Abstract
We examined the role of rumination and threat-biased interpretation in stress and growth responses to military stressors. Two online surveys were completed by 183 (survey 1) and 393 (survey 2) currently serving or retired military personnel. The surveys measured exposure to potential military stressors (exposure to combat, witnessing the consequences of war, and perceived moral injury), posttraumatic stress symptomatology (PTSS), posttraumatic growth (PTG), and personal wellbeing, with survey 1 including measures of rumination, and survey 2 including a measure of threat-biased interpretation. Path analyses revealed that indirect paths from both witnessing the consequences of war and experiencing betrayal to PTSS were mediated by intrusive rumination and threat-biased interpretation, and that indirect paths from both betrayal and transgressions by others to PTG were mediated by deliberate rumination and threat-biased interpretation. The results reveal the idiosyncratic nature of military stressors, their differential involvement with cognitions that underpin rumination about past events and interpretation of current events, and their relevance to posttraumatic stress and growth in military personnel.
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Affiliation(s)
- Brenton Russell
- School of Psychology, Deakin University, Melbourne, Australia
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24
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Gertler J, Dale L, Tracy N, Dorsett J, Sambuco N, Guastello A, Allen B, Cuffe SP, Mathews CA. Resilient, but for how long? The relationships between temperament, burnout, and mental health in healthcare workers during the Covid-19 pandemic. Front Psychiatry 2023; 14:1163579. [PMID: 37484670 PMCID: PMC10361786 DOI: 10.3389/fpsyt.2023.1163579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 06/15/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction Dispositional traits of wellbeing and stress-reaction are strong predictors of mood symptoms following stressful life events, and the COVID-19 pandemic introduced many life stressors, especially for healthcare workers. Methods We longitudinally investigated the relationships among positive and negative temperament group status (created according to wellbeing and stress-reaction personality measures), burnout (exhaustion, interpersonal disengagement), COVID concern (e.g., health, money worries), and moral injury (personal acts, others' acts) as predictors of generalized anxiety, depression, and post-traumatic stress symptoms in 435 healthcare workers. Participants were employees in healthcare settings in North Central Florida who completed online surveys monthly for 8 months starting in October/November 2020. Multidimensional Personality Questionnaire subscale scores for stress-reaction and wellbeing were subjected to K-means cluster analyses that identified two groups of individuals, those with high stress-reaction and low wellbeing (negative temperament) and those with the opposite pattern defined as positive temperament (low stress-reaction and high wellbeing). Repeated measures ANOVAs assessed all time points and ANCOVAs assessed the biggest change at timepoint 2 while controlling for baseline symptoms. Results and Discussion The negative temperament group reported greater mood symptoms, burnout, and COVID concern, than positive temperament participants overall, and negative participants' scores decreased over time while positive participants' scores increased over time. Burnout appeared to most strongly mediate this group-by-time interaction, with the burnout exhaustion scale driving anxiety and depression symptoms. PTSD symptoms were also related to COVID-19 health worry and negative temperament. Overall, results suggest that individuals with higher stress-reactions and more negative outlooks on life were at risk for anxiety, depression, and PTSD early in the COVID-19 pandemic, whereas individuals with positive temperament traits became more exhausted and thus more symptomatic over time. Targeting interventions to reduce mood symptoms in negative temperament individuals and prevent burnout/exhaustion in positive temperament individuals early in an extended crisis may be an efficient and effective approach to reduce the mental health burden on essential workers.
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Affiliation(s)
- Joshua Gertler
- UF Center for OCD, Anxiety, and Related Disorders, University of Florida, Gainesville, Florida, United States
- University of Florida, Evelyn F. and William L. McKnight Brain Institute, Gainesville, Florida, United States
- Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville, Florida, United States
| | - Lourdes Dale
- Department of Psychiatry, College of Medicine-Jacksonville, University of Florida, Jacksonville, Florida, United States
| | - Natasha Tracy
- UF Center for OCD, Anxiety, and Related Disorders, University of Florida, Gainesville, Florida, United States
- University of Florida, Evelyn F. and William L. McKnight Brain Institute, Gainesville, Florida, United States
- Department of Psychiatry, College of Medicine, University of Florida, Gainesville, Florida, United States
| | - Joelle Dorsett
- Department of Educational and Psychological Studies, School of Education and Human Development, University of Miami, Miami, Florida, United States
| | - Nicola Sambuco
- Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, Gainesville, Florida, United States
| | - Andrea Guastello
- UF Center for OCD, Anxiety, and Related Disorders, University of Florida, Gainesville, Florida, United States
- University of Florida, Evelyn F. and William L. McKnight Brain Institute, Gainesville, Florida, United States
- Department of Psychiatry, College of Medicine, University of Florida, Gainesville, Florida, United States
| | - Brandon Allen
- Department of Emergency Medicine, College of Medicine, University of Florida, Gainesville, Florida, United States
| | - Steven P. Cuffe
- Department of Psychiatry, College of Medicine-Jacksonville, University of Florida, Jacksonville, Florida, United States
| | - Carol A. Mathews
- UF Center for OCD, Anxiety, and Related Disorders, University of Florida, Gainesville, Florida, United States
- University of Florida, Evelyn F. and William L. McKnight Brain Institute, Gainesville, Florida, United States
- Department of Psychiatry, College of Medicine-Jacksonville, University of Florida, Jacksonville, Florida, United States
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Bonson A, Murphy D, Aldridge V, Greenberg N, Williamson V. Veterans' experiences of moral injury, treatment and recommendations for future support. BMJ Mil Health 2023:military-2022-002332. [PMID: 37192765 DOI: 10.1136/military-2022-002332] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 05/01/2023] [Indexed: 05/18/2023]
Abstract
INTRODUCTION Moral injury (MI) significantly impacts the lives of many UK military veterans however, there is a lack of manualised treatment to address the needs of this population. To develop future treatments that are acceptable and well tolerated, veterans should be consulted on their experiences of existing psychological treatments and suggestions for future treatments. METHODS 10 UK military veterans were interviewed about their experiences of receiving treatment for psychological difficulties after MI, and beliefs about core components of future treatments. Thematic analysis of these interviews were conducted. RESULTS 2 superordinate themes were identified: experiences of previous mental health treatment and perceptions of the proposed treatments. Reflections on cognitive behavioural therapy were mixed, with some describing that it did not ameliorate their guilt or shame. In future treatments, focusing on values, using written letters and including therapy sessions with close companions were considered beneficial. Veterans reported that a strong rapport with therapist was key for MI treatment. CONCLUSION Findings provide a useful account of how current post-trauma treatments may be experienced by patients with MI. Although limited by sample size, the results highlight therapeutic approaches that may be helpful in future and provide important considerations for therapists treating MI.
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Affiliation(s)
| | - D Murphy
- Research Department, Combat Stress, Leatherhead, UK
- King's Centre for Military Health Research, King's College London, London, UK
| | - V Aldridge
- Research Department, Combat Stress, Leatherhead, UK
| | - N Greenberg
- King's Centre for Military Health Research, King's College London, London, UK
| | - V Williamson
- King's Centre for Military Health Research, King's College London, London, UK
- Department of Experimental Psychology, Ann Watts Building, University of Oxford, Oxford, UK
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26
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He Z, Lei Q, Hu X, Xiong M, Liu J, Wen J, Shi X, Wang Z. Moral injury and suicidal ideation among health professionals: The role of mental health. J Affect Disord 2023; 333:58-64. [PMID: 37080491 PMCID: PMC10111858 DOI: 10.1016/j.jad.2023.04.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/23/2023] [Accepted: 04/14/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND The prolonged COVID-19 pandemic has burdened health professionals mentally and physically. This study aims to explore the relationship between moral injury (MI) and suicidal ideation (SI), and the role of mental health conditions in this relationship. METHODS Three-wave repeated online cross-sectional study with a total of 10,388 health professionals were conducted in different stages (2020-2022) of the COVID-19 pandemic in mainland China. Participants completed the Chinese version of the Moral Injury Symptoms Scale-Health Professional, Post-Traumatic Stress Disorder (PTSD) Checklist for DSM-5 coupled with a blanket of scales. RESULTS The prevalence of SI and MI among health professionals was 9.8 % and 40.2 %, respectively. The prevalence risk of SI was lower in wave 2 (OR = 0.64, 95 % CI: 0.54-0.77) and wave 3 (OR = 0.71, 95 % CI: 0.60-0.84) when compared with wave 1. MI (OR = 4.66, 95 % CI: 3.99-5.43), medical error (OR = 1.15, 95 % CI: 1.00-1.32), workplace violence (OR = 1.13, 95 % CI: 0.97-1.32), depression (OR = 94.08, 95 % CI: 63.37-139.69), anxiety (OR = 25.54, 95 % CI: 21.22-30.74), PTSD (OR = 24.51, 95 % CI: 19.01-31.60) were associated with a higher risk of SI. The mediation model revealed that depressive, anxiety, and PTSD symptoms explained 90.6 % of the total variance in the relationship between MI and SI. CONCLUSIONS The risk of SI has reduced among health professionals since the first peak of the COVID-19 pandemic in China. MI may contribute to prevalent SI, and mental health conditions, especially depressive symptoms, play a significant role as mediators. LIMITATIONS Cross-sectional design precludes the investigation of casual relationships. The nonrandom sampling method limits the generalization.
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Affiliation(s)
- Zhehao He
- Department of Epidemiology and Health Statistics, School of Public Health at Guangdong Medical University, Dongguan 560001, China
| | - Qiuhui Lei
- Department of Epidemiology and Health Statistics, School of Public Health at Guangdong Medical University, Dongguan 560001, China
| | - Xue Hu
- Department of Epidemiology and Health Statistics, School of Public Health at Guangdong Medical University, Dongguan 560001, China
| | - Mengyun Xiong
- Department of Epidemiology and Health Statistics, School of Public Health at Guangdong Medical University, Dongguan 560001, China
| | - Jun Liu
- Department of Preventive Medicine, School of Public Health at Zunyi Medical University, Zunyi 56006, China
| | - Jing Wen
- Department of Epidemiology and Health Statistics, School of Public Health and Management at Ningxia Medical University, China
| | - Xiuquan Shi
- Department of Epidemiology and Health Statistics, School of Public Health, Zunyi Medical University, Zunyi, Guizhou, China.
| | - Zhizhong Wang
- Department of Epidemiology and Health Statistics, School of Public Health at Guangdong Medical University, Dongguan 560001, China; The First Dongguan Affiliated Hospital, Guangdong Medical University, Dongguan 523808, China.
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Smith-MacDonald L, Jones C, Brown MRG, Dunleavy RS, VanderLaan A, Kaneva Z, Hamilton T, Burback L, Vermetten E, Brémault-Phillips S. Moving Forward from Moral Injury: A Mixed Methods Study Investigating the Use of 3MDR for Treatment-Resistant PTSD. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5415. [PMID: 37048029 PMCID: PMC10094650 DOI: 10.3390/ijerph20075415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/05/2023] [Accepted: 03/10/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Exposure to trauma and potentially morally injurious events may lead to moral injury (MI). The link between MI and posttraumatic stress disorder (PTSD) may have particularly relevant implications for treatment-resistant PTSD (TR-PTSD). Multi-modal Motion-Assisted Memory Desensitization and Reconsolidation (3MDR), a technology-assisted exposure-based trauma therapy that has been used in the treatment of PTSD, may also be an acceptable modality for patients in the treatment of TR-PTSD and MI. This proof-of-concept study aimed to investigate (1) whether MI co-occurs in military members (MMs) and veterans with TR-PTSD, and (2) the perspectives of MMs and veterans with TR-PTSD utilizing 3MDR for MI. METHODS This study employed a mixed-methods clinical trial. Military Members and veterans participated in this study (N = 11) through self-reported questionnaires, video recordings of treatment sessions, and semi-structured interviews post-session and post-intervention, with longitudinal follow-up to 6 months. RESULTS MI scores correlated with self-reported measures of mental health symptoms related to PTSD. The thematic analysis revealed three emergent themes: (1) Realities of War, (2) Wrestling Scruples, and (3) Moral Sensemaking. CONCLUSION MI was highly correlated with TR-PTSD and themes regarding MI. This result, while preliminary, allows for the postulation that MI may be contributing to the continuation of PTSD symptoms in TR-PTSD, and that 3MDR may be an acceptable modality for addressing these symptoms in MMs and veterans.
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Affiliation(s)
- Lorraine Smith-MacDonald
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation, University of Alberta, Edmonton, AB T6G 2G4, Canada
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB T6G 2G4, Canada
- St. Stephen’s College, Edmonton, AB T6G 2J6, Canada
| | - Chelsea Jones
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation, University of Alberta, Edmonton, AB T6G 2G4, Canada
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB T6G 2G4, Canada
- Alberta Health Services, Edmonton, AB T5J 3E4, Canada
| | - Matthew R. G. Brown
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation, University of Alberta, Edmonton, AB T6G 2G4, Canada
- Department of Computing Science, University of Alberta, Edmonton, AB T6G 2S4, Canada
| | | | - Annelies VanderLaan
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation, University of Alberta, Edmonton, AB T6G 2G4, Canada
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB T6G 2G4, Canada
| | - Zornitsa Kaneva
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation, University of Alberta, Edmonton, AB T6G 2G4, Canada
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB T6G 2G4, Canada
| | - Tristin Hamilton
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation, University of Alberta, Edmonton, AB T6G 2G4, Canada
- Alberta Health Services, Edmonton, AB T5J 3E4, Canada
| | - Lisa Burback
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation, University of Alberta, Edmonton, AB T6G 2G4, Canada
- Department of Psychiatry, University of Alberta, Edmonton, AB T6G 2B7, Canada
| | - Eric Vermetten
- Department of Psychiatry, Leiden University Medical Centre, Leiden University, 2333 ZA Leiden, The Netherlands
| | - Suzette Brémault-Phillips
- Heroes in Mind, Advocacy and Research Consortium (HiMARC), Faculty of Rehabilitation, University of Alberta, Edmonton, AB T6G 2G4, Canada
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB T6G 2G4, Canada
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Pre-deployment aggressiveness, combat exposure and moral injury as contributors to posttraumatic stress symptoms among combatants: A two-year prospective study. J Psychiatr Res 2023; 161:158-164. [PMID: 36931133 DOI: 10.1016/j.jpsychires.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/19/2023]
Abstract
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.
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Suicide risk among combatants: The longitudinal contributions of pre-enlistment characteristics, pre-deployment personality factors and moral injury. J Affect Disord 2023; 324:624-631. [PMID: 36621681 DOI: 10.1016/j.jad.2022.12.160] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 12/14/2022] [Accepted: 12/31/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Recent studies have shown that exposure to potentially morally injurious events (PMIEs) in deployment situations facilitates higher suicide risk among combatants. However, knowledge about pre-deployment factors that may moderate the negative contribution of PMIEs to suicide risk is rare. In this prospective study, we examined pre-enlistment characteristics and pre-deployment personality factors as possible moderators in the link between exposure to self, other, and betrayal dimensions of PMIEs and post-deployment suicide risk 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, T2-6 months following enlistment (pre-deployment), and T3-18 months following enlistment (post-deployment). Participants were assessed via semi-structured interviews of personal characteristics (e.g., cognitive index) at T1, validated self-report measures of personality factors for emotional regulation, impulsivity, and aggression at T2, and combat exposure, PMIEs, and suicide risk at T3 between 2019 and 2021. RESULTS All three dimensions of PMIEs were significantly associated with higher suicidal risk among combatants. Importantly, higher levels of pre-deployment aggression and lower levels of emotional regulation moderated the association between PMIEs and suicide risk post-deployment, above and beyond pre-enlistment psychiatric difficulties and life events. CONCLUSIONS Our results highlight the roles of pre-deployment factors of emotional regulation and aggressiveness as possible moderators in the PMIEs-suicide risk link. These results emphasize the need for higher awareness of suicide risk among deployed combatants with low emotional regulation and high aggressiveness. Moreover, tailored interventions aiming to decrease emotional dysregulation and aggressiveness levels should be considered, as such interventions may help reduce suicide risk following combat-related transgressive acts.
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Russell B, Mussap AJ. Posttraumatic stress, visual working memory, and visual imagery in military personnel. CURRENT PSYCHOLOGY 2023; 43:1-18. [PMID: 36845204 PMCID: PMC9942044 DOI: 10.1007/s12144-023-04338-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2023] [Indexed: 02/23/2023]
Abstract
Posttraumatic stress disorder (PTSD) is characterized by disruptions to cognitive functioning. Two studies were conducted to examine the relevance of military-related PTSD to two cognitive functions - visual working memory and visual imagery. Participants were military personnel who reported their PTSD diagnosis history and completed a self-administered screening tool for PTSD, the PTSD Checklist - Military Version. In Study 1, 138 personnel also completed a memory span task and a 2-back task using colored words in which Stroop interference was introduced via the semantic content of the words. In Study 2, a separate group of 211 personnel completed measures of perceived imagery vividness and spontaneous use of visual imagery. Interference effects on working memory in PTSD-diagnosed military personnel were not replicated. However, ANCOVA and structural equation modelling revealed that PTSD-intrusions were associated with poorer working memory whereas PTSD-arousal was associated with spontaneous use of visual imagery. We interpret these results as evidence that intrusive flashbacks disrupt working memory performance not by limiting memory capacity nor by interfering directly with memory functions such as inhibition, but by adding internal noise in the form of task-irrelevant memories and emotions. Visual imagery appears to be unrelated to these flashbacks but with arousal symptoms of PTSD, perhaps in the form of flashforwards about feared/anticipated threats.
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Affiliation(s)
- Brenton Russell
- School of Psychology, Deakin University, 221 Burwood Highway, 3125 Melbourne, Australia
| | - Alexander J. Mussap
- School of Psychology, Deakin University, 221 Burwood Highway, 3125 Melbourne, Australia
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31
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Exploring the Relationship Between Moral Injury and PTSD Symptoms in Suicide Attempt Survivors. COGNITIVE THERAPY AND RESEARCH 2023. [DOI: 10.1007/s10608-023-10356-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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32
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Houle SA, Inhaber J, Jetly R, Ashbaugh AR. Negative cognition in the context of suicidality after exposure to military-related potentially morally injurious events. JOURNAL OF MILITARY, VETERAN AND FAMILY HEALTH 2023. [DOI: 10.3138/jmvfh-2022-0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
LAY SUMMARY Moral injury (MI) refers to the psycho-spiritual consequences of events that deeply transgress a person’s core moral beliefs and values. Such events are reportedly common in the military context, and strong associations have been demonstrated between exposure to potentially morally injurious events (PMIEs) and suicidality. This study explored differences in negative cognitions between treatment-seeking Canadian Armed Forces members and Veterans with and without current suicidal thoughts and behaviours (STBs), all of whom reported current distress in response to a PMIE. Those exhibiting STBs reported stronger negative beliefs about the self. Scores for event-related guilt cognitions and self-blame were similar across individuals with and without STBs. Individuals reporting STBs also displayed higher depression and symptoms of posttraumatic stress disorder. The results suggest that severity of mental health symptoms and negative self-evaluations may be most pertinent in their association with suicidality in the MI context. Results remain preliminary, however, and additional research is needed to properly examine how event and self-related evaluations affect suicidality after PMIEs.
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Affiliation(s)
| | - Joseph Inhaber
- School of Psychology, University of Ottawa, Ottawa, Ontario, Canada
| | - Rakesh Jetly
- The Royal’s Institute of Mental Health Research, Ottawa, Ontario, Canada
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Culicetto L, Ferraioli F, Lucifora C, Falzone A, Martino G, Craparo G, Avenanti A, Vicario CM. Disgust as a transdiagnostic index of mental illness: A narrative review of clinical populations. Bull Menninger Clin 2023; 87:53-91. [PMID: 37871195 DOI: 10.1521/bumc.2023.87.suppa.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Disgust is a basic emotion of rejection, providing an ancestral defensive mechanism against illness. Based on research that documents altered experiences of disgust across several psychopathological conditions, we conducted a narrative review to address the hypothesis that altered disgust may serve as a transdiagnostic index of mental illness. Our synthesis of the literature from past decades suggests that, compared to healthy populations, patients with mental disorders exhibit abnormal processing of disgust in at least one of the analyzed dimensions. We also outline evidence of alterations in brain areas relevant to disgust processing, such as the insula and the interconnected limbic network. Overall, we provide preliminary support for the hypothesis that altered disgust processing may serve as a transdiagnostic index of mental illness.
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Affiliation(s)
- Laura Culicetto
- Department of Cognitive Science, University of Messina, Messina, Italy
| | | | - Chiara Lucifora
- Institute of Cognitive Science and Technology, ISTC-CNR, Rome, Italy
| | | | - Gabriella Martino
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giuseppe Craparo
- Faculty of Human and Social Sciences, UKE-Kore University of Enna, Cittadella Universitaria, Enna, Italy
| | - Alessio Avenanti
- Neuropsychology and Cognitive Neurosciences Research Center, Universidad Católica del Maule, Talca, Chile, and the Center for Studies and Research in Cognitive Neuroscience, Department of Psychology "Renzo Canestrari," Alma Mater Studiorum-University of Bologna, Cesena Campus, Cesena, Italy
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Szabó D, Békés V, Lévay EE, Salgó E, Unoka ZS. Moral injury in psychiatric patients with personality and other clinical disorders: development, psychometric properties, and validity of the Moral Injury Events Scale-Civilian Version. Eur J Psychotraumatol 2023; 14:2247227. [PMID: 37650250 PMCID: PMC10472878 DOI: 10.1080/20008066.2023.2247227] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 09/01/2023] Open
Abstract
Background: Moral injury emerges when someone perpetrates, fails to prevent, or witnesses acts that violate their own moral or ethical code. Nash et al. [(2013). Psychometric evaluation of the moral injury events scale. Military Medicine, 178(6), 646-652] developed a short measure, the Moral Injury Events Scale (MIES) to facilitate the empirical study of moral injury in the military. Our study aimed to develop a civilian version of the measure (MIES-CV) and examine its psychometric properties in a sample of psychiatric inpatients .Methods: In this cross-sectional study, the sample comprised 240 adult patients (71.7% female) with a mean age of 31.57 (SD = 11.69). The most common diagnoses in the sample were anxiety disorders (58.3%), depressive disorders (53.8%), and borderline personality disorder (39.6%). Participants were diagnosed using structured clinical interviews and filled out psychological questionnaires.Results: Exploratory factor analysis suggested that Nash et al.'s model (Perceived Transgressions, Perceived Betrayals) represents the data well. This two-factor solution showed an excellent fit in the confirmatory factor analysis, as well. Meaningful associations were observed between moral injury and psychopathology dimensions, shame, reflective functioning, well-being, and resilience. The Perceived Betrayals factor was a significant predictor of bipolar disorders, PTSD, paranoid personality disorder, borderline personality disorder, and avoidant personality disorder.Conclusions: Our study demonstrated that this broad version of the MIES is a valid measure of moral injury that can be applied to psychiatric patients.
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Affiliation(s)
- Dominik Szabó
- Doctoral School of Mental Health Sciences, Semmelweis University, Budapest, Hungary
| | - Vera Békés
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, USA
| | - Erika Evelyn Lévay
- Doctoral School of Mental Health Sciences, Semmelweis University, Budapest, Hungary
| | - Ella Salgó
- Doctoral School of Mental Health Sciences, Semmelweis University, Budapest, Hungary
| | - Zsolt Szabolcs Unoka
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
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Zerach G, Levi-Belz Y. Exposure to potentially morally injurious events, disruption in assumptive world, moral injury symptoms, and psychological distress among Israeli female veterans. Stress Health 2022. [PMID: 36525571 DOI: 10.1002/smi.3214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/02/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Gadi Zerach
- Deptartment of Psychology, Ariel University, Ariel, Israel
| | - Yossi Levi-Belz
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
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Diaz C, Ortiz V, Sanchez L, Fernandez J, Andrade EA, Akiyama MJ, Ross J. Harmful by Design-a Qualitative Study of the Health Impacts of Immigration Detention. J Gen Intern Med 2022:10.1007/s11606-022-07914-6. [PMID: 36451013 PMCID: PMC9713141 DOI: 10.1007/s11606-022-07914-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/28/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND The USA has the largest immigration detention system in the world with over 20,000 individuals imprisoned by Immigration and Customs Enforcement (ICE) daily. Numerous reports have documented human rights abuses in immigration detention, yet little is known about its health impacts. OBJECTIVE To characterize how the US immigration detention system impacts health from the perspective of people who were recently detained by ICE. DESIGN Qualitative study using anonymous, semi-structured phone interviews in English or Spanish conducted between July 2020 and February 2021. PARTICIPANTS Adults who had been detained by ICE for at least 30 days in the New York City metropolitan area within the previous 2 years, and that were fluent in English and/or Spanish. APPROACH We explored participants' health histories and experiences trying to meet physical and mental health needs while in detention and after release. We conducted a reflective thematic analysis using an inductive approach. KEY RESULTS Of 16 participants, 13 identified as male; five as lesbian, gay, bisexual, or queer; and four as Black; they were from nine countries. Participants had spent a median of 20 years living in the USA and spent a median of 11 months in immigration detention. Four themes emerged from our analysis: (1) poor conditions and inhumane treatment, (2) a pervasive sense of injustice, (3) structural barriers limiting access to care, and (4) negative health impacts of immigration detention. CONCLUSIONS The narratives illustrate how structural features of immigration detention erode health while creating barriers to accessing needed medical care. Clinicians caring for immigrant communities must be cognizant of these health impacts. Community-based alternatives to immigration detention should be prioritized to mitigate health harms.
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Affiliation(s)
- Chanelle Diaz
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA.
| | - Veronica Ortiz
- Department of Pediatrics, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Lesly Sanchez
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jose Fernandez
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Elí A Andrade
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
| | - Matthew J Akiyama
- Divisions of General Internal Medicine and Infectious Disease, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jonathan Ross
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
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Zahiriharsini A, Gilbert-Ouimet M, Langlois L, Biron C, Pelletier J, Beaulieu M, Truchon M. Associations between psychosocial stressors at work and moral injury in frontline healthcare workers and leaders facing the COVID-19 pandemic in Quebec, Canada: A cross-sectional study. J Psychiatr Res 2022; 155:269-278. [PMID: 36162193 PMCID: PMC9477440 DOI: 10.1016/j.jpsychires.2022.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/30/2022] [Accepted: 09/12/2022] [Indexed: 11/11/2022]
Abstract
Healthcare workers (HCWs) on the frontline of the COVID-19 pandemic exhibit a high prevalence of depression and psychological distress. Moral injury (MI) can lead to such mental health problems. MI occurs when perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations. Since the start of the pandemic, psychosocial stressors at work (PSWs) might have been exacerbated, which might in turn have led to an increased risk of MI in HCWs. However, research into the associations between PSWs and MI is lacking. Considering these stressors are frequent and most of them are modifiable occupational risk factors, they may constitute promising prevention targets. This study aims to evaluate the associations between a set of PSWs and MI in HCWs during the third wave of the COVID-19 pandemic in Quebec, Canada. Furthermore, our study aims to explore potential differences between urban and non-urban regions. The sample of this study consisted of 572 HCWs and leaders from the Quebec province. Prevalence ratios (PR) of MI and their 95% confidence intervals (CI) were modelled using robust Poisson regressions. Several covariates were considered, including age, sex, gender, socio-economic indicators, and lifestyle factors. Results indicated HCWs exposed to PSWs were 2.22-5.58 times more likely to experience MI. Low ethical culture had the strongest association (PR: 5.58, 95% CI: 1.34-23.27), followed by low reward (PR: 4.43, 95% CI: 2.14-9.16) and high emotional demands (PR: 4.32, 95% CI: 1.89-9.88). Identifying predictors of MI could contribute to the reduction of mental health problems and the implementation of targeted interventions in urban and non-urban areas.
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Affiliation(s)
- Azita Zahiriharsini
- Department of Health Sciences, Université du Québec à Rimouski, Quebec, Canada; CHU de Québec-Laval University Research Center, Quebec, Canada; Réseau intersectoriel de recherche en santé de l'Université du Québec (RISUQ), Quebec, Canada.
| | - Mahée Gilbert-Ouimet
- Department of Health Sciences, Université du Québec à Rimouski, Quebec, Canada,CHU de Québec-Laval University Research Center, Quebec, Canada,Réseau intersectoriel de recherche en santé de l’Université du Québec (RISUQ), Quebec, Canada
| | - Lyse Langlois
- Faculty of Social Sciences, Department of Industrial Relations, Laval University, Quebec, Canada
| | - Caroline Biron
- Department of Management, Laval University, Quebec, Canada
| | - Jérôme Pelletier
- Department of Health Sciences, Université du Québec à Rimouski, Quebec, Canada
| | | | - Manon Truchon
- School of Psychology, Laval University, Quebec, Canada,Centre de recherche interdisciplinaire en réadaptation et intégration sociale (CIRRIS), Quebec, Canada
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Winkeljohn Black S, Klinger K. Building Spiritual Strength: a Spiritually Integrated Approach to Treating Moral Injury. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2022; 9:313-320. [PMID: 36466719 PMCID: PMC9685023 DOI: 10.1007/s40501-022-00276-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/28/2022] [Indexed: 06/17/2023]
Abstract
PURPOSE OF REVIEW This article reviews a spiritually integrated group therapy, Building Spiritual Strength (BSS), designed to treat moral injury and associated syndromes (e.g., PTSD, burnout) with Gestalt and cognitive techniques and psychoeducation about spiritual coping. BSS was designed for active duty and military veterans but has since been adapted and expanded for other groups experiencing moral injury. RECENT FINDINGS Two RCTs have demonstrated BSS led to a decrease in PTSD symptoms in military members. Though BSS did not outperform a person-centered group therapy control in one RCT, the BSS group reported a decrease in spiritual struggle compared to the control. While no studies have yet been published on the expansion of BSS to new populations, emergent qualitative evidence on BSS for volunteers working with refugees indicates effectiveness in increasing positive spiritual coping. This expansion also revealed an opportunity for BSS to increase cultural humility in group members, in addition to reducing moral injury and other symptoms of distress. SUMMARY BSS is an effective, spiritually integrated means of reducing distress and improving spiritual coping. There are numerous opportunities for expansion of BSS to new populations and to test a variety of outcomes, including moral injury, spiritual flourishing, and cultural humility.
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Affiliation(s)
- Stephanie Winkeljohn Black
- College of Behavioral Sciences and Education, Penn State Harrisburg, 777 W Harrisburg Pike, Middletown, PA 17057 USA
| | - Kelsey Klinger
- College of Behavioral Sciences and Education, Penn State Harrisburg, 777 W Harrisburg Pike, Middletown, PA 17057 USA
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Fitzpatrick JJ, Pignatiello G, Kim M, Jun J, O'Mathúna DP, Duah HO, Taibl J, Tucker S. Moral Injury, Nurse Well-being, and Resilience Among Nurses Practicing During the COVID-19 Pandemic. J Nurs Adm 2022; 52:392-398. [PMID: 35815868 DOI: 10.1097/nna.0000000000001171] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine relationships between moral injury (MI), well-being, and resilience among staff nurses and nurse leaders practicing during the COVID-19 (coronavirus disease 2019) pandemic. BACKGROUND Attention to MI among health professionals, including nurses, increased in 2021, particularly related to the pandemic. Few studies examined MI, well-being, and resilience; even fewer provided implications for leadership/management. METHODS The sample included 676 RNs practicing in Ohio. The electronic survey included assessments of MI, well-being, and resilience distributed via the Ohio Nurses Association and the schools of nursing alumni Listservs. RESULTS There was a significant association between MI and negative well-being and negative association between MI and resilience. Differences were observed between staff nurses and leaders. CONCLUSIONS This is the first study relating MI, resilience, and well-bring among nurses and nurse leaders during the pandemic. There is a need for additional research to further our understanding about nurses' health and well-being during the pandemic and beyond.
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Affiliation(s)
- Joyce J Fitzpatrick
- Author Affiliations: Director, Marian K. Shaughnessy Nurse Leadership Academy, Elizabeth Brooks Ford Professor of Nursing, and Distinguished University Professor (Dr Fitzpatrick), Frances Payne Bolton School of Nursing, Case Western Reserve University; and Instructor (Dr Pignatiello), Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland: Assistant Professor (Dr Kim), College of Nursing, University of Cincinnati, Cincinnati; Assistant Professor (Dr Jun) and Associate Professor (Dr O'Mathúna), College of Nursing, The Ohio State University, Columbus; PhD Student (Mr Duah), College of Nursing, University of Cincinnati, Cincinnati; DNP Student (Ms Taibl), Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland; and Grayce Sills Endowed Professor in Psychiatric Mental Health Nursing, Director of DNP Nurse Executive Core, and Director of Implementation Science Core (Dr Tucker), Fuld EBP Institute, College of Nursing, The Ohio State University, Columbus
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Borges LM, Desai A, Barnes SM, Johnson JPS. The Role of Social Determinants of Health in Moral Injury: Implications and Future Directions. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2022; 9:202-214. [PMID: 35756696 PMCID: PMC9208749 DOI: 10.1007/s40501-022-00272-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 11/29/2022]
Abstract
Purpose of Review Exposure to potentially morally injurious events (PMIEs) and the development of moral injury have yet to be conceptualized as they relate to social determinants of health (SDoH).Recent Findings.In this paper, the extant literature on moral injury and SDoH is reviewed. Specific individual-level SDoH, including gender, sex, sexual orientation, race, and ethnicity, are explored relative to PMIEs and moral injury. The relationship among environmental SDoH, including childhood environment, justice involvement, and homelessness, is described. Summary Assessment and treatment implications are discussed, and future research directions highlighting the need for additional work addressing health inequities in moral injury are presented.
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Affiliation(s)
- Lauren M. Borges
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, 1700 N Wheeling St., Aurora, CO 80045 USA
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Alisha Desai
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, 1700 N Wheeling St., Aurora, CO 80045 USA
| | - Sean M. Barnes
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, 1700 N Wheeling St., Aurora, CO 80045 USA
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Jacob P. S. Johnson
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, 1700 N Wheeling St., Aurora, CO 80045 USA
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Disgust and Self-Disgust in Eating Disorders: A Systematic Review and Meta-Analysis. Nutrients 2022; 14:nu14091728. [PMID: 35565699 PMCID: PMC9102838 DOI: 10.3390/nu14091728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/11/2022] [Accepted: 04/19/2022] [Indexed: 12/10/2022] Open
Abstract
Disgust and self-disgust are aversive emotions which are often encountered in people with eating disorders. We conducted a systematic review and meta-analysis of disgust and self-disgust in people with eating disorders using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The systematic review of the literature revealed 52 original research papers. There was substantial heterogeneity regarding the research question and outcomes. However, we found 5 articles on disgust elicited by food images, 10 studies on generic disgust sensitivity, and 4 studies on self-disgust, and we proceeded to a meta-analytic approach on these studies. We found that women with eating disorders have significantly higher momentary disgust feelings in response to food images (1.32; 95% CI 1.05, 1.59), higher generic disgust sensitivity (0.49; 95% CI 0.24, 0.71), and higher self-disgust (1.90; 95% CI 1.51, 2.29) compared with healthy controls. These findings indicate the potential clinical relevance of disgust and self-disgust in the treatment of eating disorders.
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Abstract
Background: Modern warfare in a civilian setting may expose combatants to severe moral challenges. Whereas most of these challenges are handled effectively, some potentially morally injurious events (PMIEs) may have deleterious psychological effects on the combatants, such as suicide ideation (SI). Self-disclosure, which includes sharing distressing thoughts and emotions, has been recognized as a protective factor against SI in the aftermath of stressful events. The current study is the first to examine the moderating role of self-disclosure in the relationship between PMIE exposure and SI among combat veterans. Method: A sample of 190 recently discharged Israeli combat veterans completed validated self-report questionnaires measuring combat exposure, PMIEs, depressive symptoms, SI, and self-disclosure in a cross-sectional design study. Results: PMIE dimensions and self-disclosure significantly contributed to current SI. Notably, the moderating model indicated that self-disclosure moderated the link between PMIE-Self and current SI, as PMIE-Self and current SI demonstrated a stronger association among veterans with low self-disclosure than among those with high self-disclosure. Limitations: Cross-sectional design of volunteers, the findings may not be directly generalizable to veterans' population. Conclusion: Self-disclosure, as a factor promoting a sense of belongingness, interpersonal bonding, and support, might diminish SI risk following PMIE exposure. Various mechanisms accounting for these associations are suggested, and the clinical implications of these interactions are discussed.
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Affiliation(s)
- Yossi Levi-Belz
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel
| | - Sharon Shemesh
- The Lior Tsfaty Center for Suicide and Mental Pain Studies, Ruppin Academic Center, Emek Hefer, Israel.,Department of Clinical Psychology, Ruppin Academic Center, Emek Hefer, Israel
| | - Gadi Zerach
- Department of Behavioral Sciences and Psychology, Ariel University, Ariel, Israel
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de Vroege L, van den Broek A. Substantial Impact of COVID-19 on Self-Reported Mental Health of Healthcare Professionals in the Netherlands. Front Public Health 2022; 9:796591. [PMID: 35083191 PMCID: PMC8785205 DOI: 10.3389/fpubh.2021.796591] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 12/13/2021] [Indexed: 12/12/2022] Open
Abstract
Initially, the COVID-19 pandemic caused a continued pressure on professionals working in hospitals due to the increase of affected patients. At the moment, the pandemic continues but thanks to all kinds of measures (e.g., social distancing) workload seems to decrease at the hospitals. On the contrary, patients with long-lasting symptoms due to COVID-19 infection or the pandemic begin to merge at the mental healthcare institutions in the Netherlands but this also holds true for other countries. Furthermore, healthcare professionals are affected by safety measures such as working from home, which led to an increased feeling of stress and may have led to a misbalance in work and private life. As a result, the question whether healthcare employees in mental healthcare experience impaired mental health remains unclear and chances are fair that mental health problems such as exhaustion and burnout may be prevalent. This study describes an online survey in which mental health amongst mental healthcare professionals is investigated. About 1,300 professionals from a large number of mental healthcare institutions replied the survey. Around 50% of the respondents experienced increased levels of stress. Feelings of anxiety, anger, and sadness were also increasingly experienced due to the COVID-19 pandemic. Furthermore, 4.2% replied that they were considering resigning their jobs which is alarming considering the shortage of healthcare professionals in mental healthcare institutions. The results support the importance of treatment or support of professionals in mental healthcare that experience psychological ailments.
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Affiliation(s)
- Lars de Vroege
- Tranzo Department, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, Netherlands.,Department of Anxiety and Depression, GGz Breburg, Breda, Netherlands
| | - Anneloes van den Broek
- Department of Anxiety and Depression, GGz Breburg, Breda, Netherlands.,Department of Post Academic Psychology Training and Education, Breburg Academy, GGz Breburg, Tilburg, Netherlands
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Morally Distressing Experiences, Moral Injury, and Burnout in Florida Healthcare Providers during the COVID-19 Pandemic. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182312319. [PMID: 34886045 PMCID: PMC8656473 DOI: 10.3390/ijerph182312319] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/16/2021] [Accepted: 11/19/2021] [Indexed: 12/12/2022]
Abstract
Because healthcare providers may be experiencing moral injury (MI), we inquired about their healthcare morally distressing experiences (HMDEs), MI perpetrated by self (Self MI) or others (Others MI), and burnout during the COVID-19 pandemic. Participants were 265 healthcare providers in North Central Florida (81.9% female, Mage = 37.62) recruited via flyers and emailed brochures that completed online surveys monthly for four months. Logistic regression analyses investigated whether MI was associated with specific HMDEs, risk factors (demographic characteristics, prior mental/medical health adversity, COVID-19 protection concern, health worry, and work impact), protective factors (personal resilience and leadership support), and psychiatric symptomatology (depression, anxiety, and PTSD). Linear regression analyses explored how Self/Others MI, psychiatric symptomatology, and the risk/protective factors related to burnout. We found consistently high rates of MI and burnout, and that both Self and Others MI were associated with specific HMDEs, COVID-19 work impact, COVID-19 protection concern, and leadership support. Others MI was also related to prior adversity, nurse role, COVID-19 health worry, and COVID-19 diagnosis. Predictors of burnout included Self MI, depression symptoms, COVID-19 work impact, and leadership support. Hospital administrators/supervisors should recognize the importance of supporting the HCPs they supervise, particularly those at greatest risk of MI and burnout.
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Abstract
Palliative care practitioners have encountered morally distressing situations during the COVID-19 pandemic, and have supported their colleagues experiencing moral distress. Familiarity with the concept of moral distress and with COVID-specific causes of moral distress may help palliative care practitioners recognize moral distress in themselves and in their colleagues. This essay provides a brief review of the concept of moral distress, a list of potential COVID-19 specific causes of moral distress, and a list of organizational, team, and individual interventions to promote resilience.
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Affiliation(s)
- Elizabeth K Vig
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.,Geriatrics and Extended Care, VA Puget Sound Health Care System, Seattle, Washington, USA
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