A latent profile analysis of moral injury appraisals in refugees

Moral injury appraisals and posttraumatic stress symptoms in trauma-exposed police officers: a latent class analysis

Background: Police officers encounter various potentially traumatic events (PTEs) and may be compelled to engage in actions that contradict their moral codes. Consequently, they are at risk to develop symptoms of Posttraumatic Stress Disorder (PTSD), but also moral stress or moral injury (MI). To date, MI in police officers has received limited attention.Objective: The present study sought to identify classes of MI appraisals and PTSD symptoms among police officers exposed to PTEs, while also investigating potential clinical differences between these classes.Method: For this study, 421 trauma-exposed police officers were assessed on demographics and several clinical measurements including MI appraisals (self-directed and other-directed), PTSD severity, and general psychopathology. Latent class and regression analyses were conducted to examine the presence of different classes among trauma-exposed police officers and class differentiation in terms of demographics, general psychopathology, PTSD severity, mistrust, guilt, self-punishment, and feelings of worthlessness.Results: The following five classes were identified: (1) a 'Low MI, high PTSD class' (28%), (2) a 'High MI, low PTSD class' (11%), (3) a 'High MI, high PTSD class' (17%), (4) a 'Low MI, low PTSD class' (16%), and (5) a 'High MI-other, high PTSD class' (27%). There were significant differences between the classes in terms of age, general psychopathology, PTSD severity, mistrust, guilt, and self-punishment but no differences for gender and feelings of worthlessness.Conclusion: In conclusion, we identified five classes, each exhibiting unique patterns of cognitive MI appraisals and PTSD symptoms. This underscores the criticality of measuring and identifying MI in this particular group, as it allows for tailored treatment interventions.

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

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

Civilian Moral Injury and Amygdala Functional Connectivity During Attention to Threat

BACKGROUND

Moral injury references emotional and spiritual/existential suffering that may emerge following psychological trauma. Despite being linked to adverse mental health outcomes, little is known about the neurophysiological mechanisms of this phenomenon. In this study, we examined neural correlates of moral injury exposure and distress using the Moral Injury Exposure and Symptom Scale for Civilians. We also examined potential moderation of these effects by race (Black vs. White individuals) given the likely intersection of race-related stress with moral injury.

METHODS

Forty-eight adults ages 18 to 65 years (mean age = 30.56, SD = 11.93) completed the Moral Injury Exposure and Symptom Scale for Civilians and an affective attentional control measure, the affective Stroop task (AS), during functional magnetic resonance imaging; the AS includes presentation of threat-relevant and neutral distractor stimuli. Voxelwise functional connectivity of the bilateral amygdala was examined in response to threat-relevant versus neutral AS distractor trials.

RESULTS

Functional connectivity between the right amygdala and left postcentral gyrus/primary somatosensory cortex was positively correlated with the Moral Injury Exposure and Symptom Scale for Civilians exposure score (voxelwise p < .001, cluster false discovery rate-corrected p < .05) in response to threat versus neutral AS distractor trials. Follow-up analyses revealed significant effects of race; Black but not White participants demonstrated this significant pattern of amygdala-left somatosensory cortex connectivity.

CONCLUSIONS

Increased exposure to potentially morally injurious events may lead to emotion-somatosensory pathway disruptions during attention to threat-relevant stimuli. These effects may be most potent for individuals who have experienced multilayered exposure to morally injurious events, including racial trauma. Moral injury appears to have a distinct neurobiological signature that involves abnormalities in connectivity of emotion-somatosensory paths, which may be amplified by race-related stress.

Light Personality Style and Moral Injury Among Chinese Health Professionals

Moral injury has attracted attention widely in various occupations, particularly health professionals. Personality traits involve the professional values in clinical decision-making associated with mental outcomes. The current study examines the relationship between "light personality" style and moral injury. Scores on three subscales of the Light Triad Scale were negatively correlated with the Moral Injury Symptoms Scale-Health Professional. Health professionals more likely to have light personality styles may be less likely to suffer from moral injury under high-stake situations. The findings provide evidence to better understand the inner core of the moral injury, suggesting a potential pathway to improve the moral well-being of health professionals by strengthening key elements of light personality.

Moral Injury is a Risk Factor for Substance Use and Suicidality Among US Military Veterans with and without Traumatic Brain Injury

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.

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

We evaluated longitudinal associations between subjective appraisals of transgressions of moral beliefs, values, and expectations (potential morally injurious events; PMIEs) and suicidal ideation (SI) among recently discharged combat veterans. Participants were 374 active-duty Israeli combatants who participated in a five-year longitudinal study with four measurement points: T1- one year before enlistment, T2- one month before discharge from army service, and then again six months and twelve months following discharge (T3 and T4, respectively). A history of lifetime suicidal ideation and behavior was associated with higher levels of subjective appraisals of PMIEs, as compared to no history of suicidal ideation and behavior. Above and beyond pre-enlistment personal characteristics, cross-lagged pathway analyses indicated significant bi-directional pathways between subjective appraisals of PMIEs and SI. For all PMIEs dimensions, SI was associated with greater subjective appraisals of PMIEs, on subsequent measurement. However, cross-lagged effects of PMIEs-'other' (T2) predicting SI (T3) and PMIEs-'betrayal' (T3) predicting SI (T4) were also found. Our findings are the first to provide evidence of longitudinal, temporal associations between subjective appraisals of PMIEs and SI, which might serve as potential intervention targets among recently discharged traumatized veterans.

A prospective investigation of protective factors for moral injury and psychiatric symptomatology among Israeli combatants: A Latent Class Analysis approach

BACKGROUND

In this prospective study, we examined pre-enlistment characteristics and pre-deployment protective factors of exposure to potentially morally injurious events (PMIEs) among Israeli active-duty combatants, as well as psychiatric symptomatology outcomes of exposure.

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' characteristics were assessed via semi-structured interviews (T1) and validated self-report measures (T2-T3) between 2019 and 2021.

RESULTS

Latent Class Analysis (LCA) was used to identify three classes characterized by unique patterns of exposure to PMIEs (T2): Minimal Exposure (56.6%), Betrayal-Only (25.5%), and High Exposure (17.8%). Higher levels of pre-deployment psychological flexibility (T1) were associated with higher odds for inclusion in the high exposure class (T2). As compared to the minimal exposure class, both high exposure and betrayal-only classes were associated with higher levels of mental health symptoms and MI-related psychological outcomes (T2).

CONCLUSIONS

This is the first prospective study of antecedents and outcomes of exposure to PMIEs among active-duty combatants. Clinicians treating combatants should be aware of the different types of exposure to PMIEs and their possible psychiatric outcomes.

Moral injury among U.S. combat veterans with and without PTSD and depression

BACKGROUND

Questions persist about how often potentially morally injurious events (PMIEs) are associated with posttraumatic stress disorder (PTSD) and depression.

METHODS

This study examined the overlap of morally injurious events with probable PTSD and depression in a nationally representative sample of U.S. combat veterans (n = 1,321, mean age 59.1, 93.7% male).

RESULTS

Most veterans with probable PTSD (72.2%), probable depression (72.4%), and probable PTSD and/or depression (68.4%), endorsed experiencing PMIEs; 31.1-35.3% of these participants endorsed perpetration, 45.1-50.4% endorsed witnessing others, and 52.6-55.7% endorsed betrayal. The prevalence of PMIEs among veterans without current probable PTSD and/or depression was 33.7%, 32.3%, and 31.5%, respectively; 7.9-9.1% of these participants endorsed perpetration-based PMIEs, 19.2-20.3% witnessing, and 19.8-21.8% endorsed betrayal. PMIEs were more prevalent among veterans with probable PTSD or depression relative to those without (ORs ranging 2.14-3.32; p's &lt; 0.001).

CONCLUSIONS

This is the first nationally representative study to examine the prevalence of PMIEs among veterans with and without probable PTSD or depression. Results highlight the importance of understanding distress and functional impairment in these veterans to evaluate whether they may benefit from intervention. PMIEs were strikingly more prevalent among veterans with probable PTSD and depression, suggesting that veterans without PMIEs are the minority among combat veterans with these disorders.

The longitudinal association between moral injury appraisals and psychological outcomes in refugees

BACKGROUND

Refugees report a diverse array of psychological responses following persecution and displacement. Little is known, however, regarding the mechanisms that underlie differential psychological reactions in refugees. This study investigated the longitudinal impact of negative moral appraisals about one's own actions [i.e. moral injury-self (MI-self) appraisals] and others' actions [i.e. moral injury-other (MI-others) appraisals] on a variety of psychological symptoms over a period of 6 months.

METHODS

Participants were 1085 Arabic, Farsi, Tamil, or English-speaking refugees who completed a survey at baseline and 6 months later either on-line or via pen-and-paper. The survey indexed demographic factors, exposure to potentially traumatic events (PTEs), exposure to ongoing stressors, MI-other appraisals, MI-self appraisals, re-experiencing and arousal symptoms, and feelings of sadness, anger and shame.

RESULTS

Findings indicated that, after controlling for demographics, PTE exposure and ongoing stressors, MI-other appraisals predicted increased re-experiencing and hyperarousal symptoms, and feelings of sadness and shame. MI-self appraisals predicted decreased feelings of shame, and decreased re-experiencing symptoms. In contrast, psychological symptoms at baseline did not as strongly influence MI appraisals 6 months later.

CONCLUSIONS

These findings highlight the important role that cognitive appraisals of adverse events play in the longitudinal course of psychological symptoms. These results thus have important implications for the development of tailored psychological interventions to alleviate the mental health burden held by refugees.

Moral injury events and behavioral health outcomes among American veterans

Among American veterans, the behavioral health impact of potentially morally injurious experiences (PMIEs) has recently garnered attention. There is heterogeneity in the types of experiences that are classified as PMIEs, and different PMIEs may be differentially associated with various outcomes. We aimed to explore heterogeneity in PMIEs among veterans, and whether PMIE classes are differentially associated with several behavioral health outcomes (i.e., symptoms of posttraumatic stress disorder, depression, anxiety, and anger). Data were from a survey study of veteran health attitudes and behavior (N=1004). We employed a Latent Class Analysis approach to identify sub-groups of participants with similar PMIE response patterns on the Moral Injury Events Scale and to determine the relationship between class membership and behavioral health outcomes. A 4-class solution best fit our data, with classes including (1) high all, (2) witnessed transgressions, (3) troubled by failure to act, and (4) moderate all. There was a link between class membership and behavioral health, with the high all class and moderate all classes consistently reporting especially poor outcomes. Our results are in line with cumulative stress models suggesting exposure to multiple forms of adversity may place individuals at particular risk of poor health and functioning. Clinicians working with veterans should screen for exposure to the full range of PMIE types and be prepared to address the multitude of behavioral health impacts.

Profiles of post-migration stressors and mental health in refugees: A latent class analysis

Studies have documented the mental health effects of pre-migration trauma on resettled refugees and identified distinct psychological symptom profiles using person centred statistical techniques (e.g., latent class analysis; LCA). These techniques have advanced our understanding of the complex presentation of trauma and psychopathology in refugees. The current study employs LCA to examine patterns of exposure to stressors including post-migration stressors, allowing us to identify patterns of post-migration stress exposure and their association with mental health outcomes. Participants were 1085 Arabic, Farsi, Tamil, or English speaking adult refugees. Pre-migration trauma, post-migration stressors, PTSD, depression, anger, and functional impairment was measured. LCA was conducted to identify distinct classes of post-migration stressors and associations with mental health and adjustment in the resettlement environment. Latent class analysis revealed 5 classes of participants: high difficulties class (7.2%), immigration fear class (14.4%), social disconnection class (17.3%), moderate difficulties class (28.9%) and a low difficulties class (32.3%). Each of the five classes shared commonalities in addition to key differences associated with specific demographic characteristics and psychopathology. Post-migration stressors appear to map onto distinct profiles, which uniquely contribute to functional impairment and mental health outcomes in refugees. These findings have substantial implications for public health and social services working with resettled refugee communities.

Moral injury related to immigration detention on Nauru: a qualitative study

Background

Immigration detention is associated with detrimental mental health outcomes but little is known about the underlying psychological processes. Moral injury, the experience of transgression of moral beliefs, may play an important role.

Objective

Our aim was to explore moral injury appraisals and associated mental health outcomes related to immigration detention on Nauru.

Methods

In this retrospective study, we conducted in-depth interviews with 13 individuals who had sought refuge in Australia and, due to arriving by boat, had been transferred to immigration detention on Nauru. At the time of the study, they lived in Australia following medical transfer. We used reflexive thematic analysis to develop themes from the data.

Results

Major themes included 1) how participants' home country experience and the expectation to get protection led them to seek safety in Australia; 2) how they experienced deprivation, lack of agency, violence, and dehumanization after arrival, with the Australian government seen as the driving force behind these experiences; and 3) how these experiences led to feeling irreparably damaged. The participant statement 'In my country they torture your body but in Australia they kill your mind.' conveyed these three key themes in our analysis.

Conclusion

Our findings suggest that moral injury may be one of the processes by which mandatory immigration detention can cause harm. Although refugees returned to Australia from offshore detention may benefit from interventions that specifically target moral injury, collective steps are needed to diminish deterioration of refugee mental health. Our results highlight the potentially deleterious mental health impact of experiencing multiple subtle and substantial transgressions of one's moral frameworks. Policy makers should incorporate moral injury considerations to prevent eroding refugee mental health.

Moderating role of moral injury in the mental health of adolescent refugees

OBJECTIVE

This study investigated whether moral injury appraisals moderated the relationships between trauma, postmigration living difficulties, resilience, and mental health outcomes in adolescent refugees.

METHOD

Eighty-five adolescent refugees from a community sample completed an online survey.

RESULTS

A significant interaction was found between moral injury and discrimination for externalizing and posttraumatic stress disorder (PTSD) symptoms; adolescents whom had experienced high levels of discrimination combined with high levels of moral injury had poorer mental health. A significant interaction was found between moral injury and resilience for internalizing symptoms: high levels of resilience appeared to buffer the association between moral injury and internalizing symptoms. Contrary to predictions, stressful life experiences and postmigration living difficulties did not interact significantly with moral injury to predict mental health.

CONCLUSIONS

Discrimination may contribute to perpetuating poor mental health in adolescent refugees with high levels of moral injury. Resilience may buffer some of the negative effects of moral injury.

The impact of morally injurious events in a refugee sample: A quantitative and qualitative study

BACKGROUND

Posttraumatic Stress Disorder (PTSD) is often reported by refugees that faced violence and persecution. Some stressful events may also entail moral conflicts or dilemmas, described as "potentially morally injurious events" (PMIE). Very few studies have yet investigated the nature of these PMIEs in traumatized refugees, using both quantitative and qualitative data.

METHOD

For this retrospective study, secondary data analysis was used to examine the traumatic events of 183 patients. Based on established definitions of a PMIE, participants were allocated to a Moral Injury (MI) group if they reported lasting distress after exposure to an event of which they indicated that it transgressed their moral beliefs. The remaining participants were allocated to the No-MI group. The type of PMIEs was categorized using qualitative analysis. The groups were compared in terms of PTSD severity, feelings of guilt, and general mental health symptoms.

RESULTS

Of the total sample, 55 participants reported one or more acts of transgression (MI group) and 128 reported no acts of transgression (No-MI group). Analyses of PMIEs revealed six themes 1) failing to prevent harm to others, 2) not giving aid to people in need, 3) leaving family members behind that consequently lead to injury or death of others, 4) making indirect and direct moral decisions leading to injury or death of others, 5) betrayal, and 6) engaging in the harm of others. No differences were found between groups on the clinical outcomes, except for feelings of guilt.

CONCLUSION

A considerable number of traumatized refugees reported confrontation with PMIEs. Experiencing PMIEs appeared unrelated to elevated posttraumatic mental health issues.

Mental health symptoms in Public Safety Personnel: Examining the effects of adverse childhood experiences and moral injury

BACKGROUND

Adverse Childhood Experiences (ACEs) increase risk for negative mental health outcomes in adulthood; however, the mechanisms through which ACEs exert their influence on adult mental health are poorly understood. This is particularly true for Public Safety Personnel (PSP; e.g., police, firefighters, paramedics, etc.), a group with unique vulnerability to negative psychiatric sequalae given their chronic exposure to potentially traumatic, work-related events.

OBJECTIVES

To examine the role of moral injury (MI) and emotion regulation in the relation between ACEs and adult mental health symptoms in adulthood.

PARTICIPANTS AND SETTING

Participants (N = 294) included a community sample of Canadian and American PSP members aged 22 to 65.

METHODS

The current study uses cross-sectional data collection via retrospective self-report questionnaires administered between November, 2018 and November, 2019 to assess level of ACEs (ACE-Q), emotion regulation difficulties (DERS) and symptoms of post-traumatic stress (PCL-5), dissociation (MDI), depression, stress, and anxiety (DASS-21). Additionally, participants completed the Moral Injury Assessment for Public Safety Personnel, the first measure of MI developed specifically for PSP.

RESULTS

Path analysis revealed that ACEs significantly predicted adverse mental health symptoms in adulthood; this effect was mediated by symptoms of MI and moderated by difficulties with emotion regulation.

CONCLUSIONS

This study is the first to identify MI as a mechanism involved in the relation between ACEs and adult psychopathology and highlights the protective role of emotion regulation skills. These findings can inform the development of future research and clinical interventions in PSP populations.

Moral injury, mental health and behavioural health outcomes: A systematic review of the literature

Despite a burgeoning of research on moral injury in the past decade, existing reviews have not explored the breadth of consequences and the multitude of pathways through which moral injury and potentially morally injurious experiences (PMIEs) influence mental and behavioural health outcomes. This study aimed to identify associations between moral injury on mental and behavioural health. Literature searches of psychological and medical databases were conducted through April 2020. Eligible studies measured moral injury or PMIEs, and health outcomes (e.g., depression, substance use and suicidality). Fifty-seven publications representing 49 separate samples were included. Studies examined the impact of moral injury on post-traumatic stress disorder (PTSD) (n = 43); depression (n = 32); anxiety (n = 15); suicide (n = 15); substance use (n = 14); and 'other' health outcomes, including pain, burnout, sleep disturbance and treatment-seeking behaviours (n = 11). The majority of studies found significant positive associations between moral injury-related constructs, mental health and behavioural health outcomes; however, the majority were also cross-sectional and focused on military samples. Proposed mediators included lack of social support, negative cognitions and meaning-making. Moderators included self-compassion, pre-deployment mental health education and mindfulness. Moral injury is associated with a variety of negative health outcomes. Research is needed to determine the mechanisms by which moral injury may influence these outcomes over time.

Patterns of exposure to potentially morally injurious events among Israeli combat veterans: A latent class analysis approach

OBJECTIVE

Following exposure to events that transgress moral beliefs and expectations rooted in cultural, organizational, and group-based ethical rules, veterans can experience psychological, social, and spiritual problems referred to as Moral Injury (MI). We examined patterns of exposure to potentially morally injurious events (PMIEs) among Israeli veterans as well as psychological and functional correlates of exposure.

METHOD

A sample of 381 Israeli veterans volunteered to complete a cross-sectional electronic survey between 2017-2018. Latent Class Analysis (LCA) was used to identify classes characterized by unique patterns of exposure to PMIEs and compare differences in psychological and functional problems.

RESULTS

Three subgroups were identified: Moral Injury (12.1 %), Betrayal-Only (20.8 %), and Minimal Exposure (67.1 %). Whereas those in the betrayal-only class reported more traditional posttraumatic symptoms and those in the moral injury class reported more moral injury symptoms (i.e., guilt-related cognitions), some psychological problems were shared by veterans assigned to the moral injury and betrayal-only classes (e.g., entrapment). Importantly, while both those in the betrayal-only and moral injury classes had lower forgiveness relative to those in the minimal exposure class, those in the betrayal-only class received more familial support than did those in the moral injury class.

CONCLUSIONS

The study's findings offer an overview of the complex associations between patterns of exposure to PMIEs and associated outcomes. Clinicians treating veterans coping with combat trauma should be aware of the unique and shared symptoms reported by those with moral injury and betrayal exposures.

Moral injury and mental health outcomes among Israeli health and social care workers during the COVID-19 pandemic: a latent class analysis approach

BACKGROUND

The COVID-19 pandemic poses unique challenges to health and social care workers (HSCWs) who face morally challenging and life-threatening decisions. Following exposure to events that transgress moral beliefs and expectations, HSCWs might experience psychological, social, and spiritual problems referred to as Moral Injury (MI).

OBJECTIVE

The objectives of this study were to examine patterns of exposure to potentially morally injurious events (PMIEs) among HSCWs and their associations with MI, mental health outcomes and psychological correlates.

METHOD

A sample of 296 Israeli HSCWs volunteered to complete a cross-sectional electronic survey with validated self-report questionnaires in February and March 2021. Latent Class Analysis (LCA) was used to identify classes characterized by unique patterns of exposure to PMIEs. Socio-demographic, work and COVID-related variables were used to predict patterns of exposure to PMIEs, and differences in mental-health outcomes and psychological correlates between classes were assessed.

RESULTS

Three subgroups were identified: 'high exposure' (19.5%), 'betrayal-only' (31.3%), and 'minimal exposure' (49.4%). Perceived stress increases the odds for inclusion in the 'high exposure' and 'betrayal-only' classes. Participants in both the High Exposure class and the betrayal-only classes reported higher levels of depressive, anxiety, posttraumatic and more moral injury symptoms as compared to the 'minimal exposure' class. Importantly, both 'high exposure' and 'betrayal-only' classes reported lower levels of self-compassion and higher levels of self-criticism, relative to those in the 'minimal exposure' class.

CONCLUSIONS

The study's findings offer an overview of the complex associations between patterns of exposure to PMIEs and associated predictors and outcomes. Clinicians treating HSCWs coping with COVID-19 related stress should be aware of the contribution of exposure to PMIEs to HSCWs' distress and to the unique constellation of high self-criticism and low self-compassion among HSCWs with exposure to PMIEs.

Moral injury in civilians: associations with trauma exposure, PTSD, and suicide behavior

BACKGROUND

Moral injury (MI) describes emotional, spiritual, and social suffering that can arise following psychological trauma. Prior research in military pop ulations indicates the relevance of MI to adverse psychological outcomes, such as post-traumatic stress disorder (PTSD) and suicidal behaviours, and shows evidence for MI as a unique construct. Minimal studies of MI have been implemented in civilians, usually restricted to small samples with a specific set of traumatic experiences, despite the conceptual relevance of MI to non-military trauma reactions more broadly (e.g. feelings of betrayal towards a perpetrator of sexual abuse).

OBJECTIVE

To address this problem, we assessed MI in trauma-exposed civilians to examine ways in which this construct was related to and distinct from trauma and traumatic stress-related problems, including PTSD and depression.

METHOD

We adapted an existing MI scale, Moral Injury Events Scale (MIES) and administered this measure to 81 men and women along with measures of trauma exposure, PTSD and depression, and also asked participants about past suicide attempts.

RESULTS

We observed that both greater exposure and distress related to potentially morally injurious events were associated with higher trauma exposure, particularly childhood maltreatment, as well as post-traumatic and depressive psychopathology. However, even after accounting for current PTSD and depression symptoms, MI exposure (F = 6.05, p = .017) was significantly higher among participants who had previously attempted suicide.

CONCLUSIONS

These pilot data reveal the ways in which MI is associated with trauma exposure, PTSD and depression and highlight the salience of MI in civilians. Similarly, these data demonstrate the unique relevance of MI to suicide behaviours, independent of post-traumatic psychopathology, indicating that this construct may be an understudied contributor to suicide risk in civilians.

Empathy is key in the development of moral injury

Background: Moral injury is a relatively new field within psychotraumatology that focuses on understanding and treating psychosocial symptoms after exposure to potentially morally injurious events (PMIE's). There are currently three models of the development of moral injury which centre around the influence of attributions, coping and exposure. While the capacity for empathy is known to underlie moral behaviour, current models for moral injury do not explicitly include empathy-related factors. Objective: This paper aims to make a case for complementing current models of the development of moral injury with the perception-action model of empathy (PAM). Method: In this paper, the perception-action mechanism of empathy and the empathic behaviour that it may initiate, are described. The PAM states that perception of another person's emotional state activates the observer's own representations of that state. This forms the basis for empathic behaviour, such as helping, by which an observer tries to alleviate both another person's and their own, empathic, distress. In this paper it is proposed that in PMIE's, empathic or moral behaviour is expected but not, or not successfully, performed, and consequently distress is not alleviated. Factors known to influence the empathic response, including attention, emotion-regulation, familiarity and similarity, are hypothesized to also influence the development of moral injury. Results: Two cases are discussed which illustrate how factors involved in the PAM may help explain the development of moral injury. Conclusions: As empathy forms the basis for moral behaviour, empathy-related factors are likely to influence the development of moral injury. Research will have to show whether this hypothesis holds true in actual practice.