Defining and Assessing the Syndrome of Moral Injury:Initial Findings of the Moral Injury Outcome Scale Consortium

Potentially morally injurious events (PMIEs) entail acts of commission (e.g., cruelty, proscribed or prescribed violence) or omission (e.g., high stakes failure to protect others) and bearing witness (e.g., to grave inhumanity, to the gruesome aftermath of violence), or being the victim of others' acts of commission (e.g., high stakes trust violations) or omission (e.g., being the victim of grave individual or systemic failures to protect) that transgress deeply held beliefs and expectations about right and wrong. Although there is a proliferation of interest in moral injury (the outcome associated with exposure to PMIEs), there has been no operational definition of the putative syndrome and no standard assessment scheme or measure, which has hampered research and care in this area. We describe an international effort to define the syndrome of moral injury and develop and validate the Moral Injury Outcome Scale (MIOS) in three stages. To ensure content validity, in Stage I, we conducted interviews with service members, Veterans, and clinicians/Chaplains in each country, inquiring about the lasting impact of PMIEs. Qualitative analysis yielded six operational definitions of domains of impact of PMIEs and components within domains that establish the parameters of the moral injury syndrome. From the domain definitions, we derived an initial pool of scale items. Stage II entailed scale refinement using factor analytic methods, cross-national invariance testing, and internal consistency reliability analyses of an initial 34-item MIOS. A 14-item MIOS was invariant and reliable across countries and had two factors: Shame-Related (SR) and Trust-Violation-Related (TVR) Outcomes. In Stage III, MIOS total and subscale scores had strong convergent validity, and PMIE-endorsers had substantially higher MIOS scores vs. non-endorsers. We discuss and contextualize the results and describe research that is needed to substantiate these inaugural findings to further explore the validity of the MIOS and moral injury, in particular to examine discriminant and incremental validity.</p

Defining and Assessing the Syndrome of Moral Injury:Initial Findings of the Moral Injury Outcome Scale Consortium

Potentially morally injurious events (PMIEs) entail acts of commission (e.g., cruelty, proscribed or prescribed violence) or omission (e.g., high stakes failure to protect others) and bearing witness (e.g., to grave inhumanity, to the gruesome aftermath of violence), or being the victim of others' acts of commission (e.g., high stakes trust violations) or omission (e.g., being the victim of grave individual or systemic failures to protect) that transgress deeply held beliefs and expectations about right and wrong. Although there is a proliferation of interest in moral injury (the outcome associated with exposure to PMIEs), there has been no operational definition of the putative syndrome and no standard assessment scheme or measure, which has hampered research and care in this area. We describe an international effort to define the syndrome of moral injury and develop and validate the Moral Injury Outcome Scale (MIOS) in three stages. To ensure content validity, in Stage I, we conducted interviews with service members, Veterans, and clinicians/Chaplains in each country, inquiring about the lasting impact of PMIEs. Qualitative analysis yielded six operational definitions of domains of impact of PMIEs and components within domains that establish the parameters of the moral injury syndrome. From the domain definitions, we derived an initial pool of scale items. Stage II entailed scale refinement using factor analytic methods, cross-national invariance testing, and internal consistency reliability analyses of an initial 34-item MIOS. A 14-item MIOS was invariant and reliable across countries and had two factors: Shame-Related (SR) and Trust-Violation-Related (TVR) Outcomes. In Stage III, MIOS total and subscale scores had strong convergent validity, and PMIE-endorsers had substantially higher MIOS scores vs. non-endorsers. We discuss and contextualize the results and describe research that is needed to substantiate these inaugural findings to further explore the validity of the MIOS and moral injury, in particular to examine discriminant and incremental validity.</p

The associations between pathological narcissism, alexithymia and disordered eating attitudes among participants of pro-anorexic online communities

Abstract Purpose This study investigated the relationships between pathological narcissism, alexithymia, and disordered eating attitudes among participants of pro-anorexic online communities. Specifically, we explored the possible moderating role of alexithymia in the relationships between narcissistic vulnerability and disordered eating attitudes. Methods Participants included 97 Israeli female young adults who are active participants in pro-anorexic online communities. These participants completed a battery of self-reported questionnaires: The Pathological Narcissism Inventory (PNI); The Eating Attitudes Test-26 (EAT-26); and The Toronto Alexithymia Scale (TAS-20). Results Narcissistic grandiosity, vulnerability, and alexithymia were positively related to disordered eating attitudes. Alexithymia moderated the relationships between narcissistic vulnerability and the total score of disordered eating attitudes. Furthermore, alexithymia moderated the relationships between both narcissistic vulnerability and grandiosity and the oral control subscale of EAT-26. Conclusions These findings highlight the interaction between the pathological narcissism and the fundamental trait of alexithymia that might put individuals at risk for disordered eating

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

The interpersonal implications of PTSD and complex PTSD: The role of disturbances in self-organization

BACKGROUND: In the aftermath of trauma not only the primary traumatized survivors' mental health is affected but often also their significant others. The current study explores the specific associations of ICD-11 symptoms of posttraumatic stress disorder (PTSD) and disturbances in self organization (DSO) for secondary traumatic stress and dyadic adjustment among both spouses. METHODS: Male Israeli veterans and their wives (N = 216) were assessed 30 years after the war. Primary PTSD/DSO symptoms of the veterans and secondary posttraumatic stress symptoms (secondary PTSS)/DSO of the wives were assessed. Actor Partner Independence Modelling (APIM) evaluated the differential effects of PTSD and DSO for trauma transmission and dyadic adjustment. RESULTS: While veterans' primary PTSD only related to secondary PTSS of the wives, the veterans' DSO predicted the wives' secondary PTSS as well as DSO. Moreover, the APIM revealed that the primary and secondary DSO of both partners were associated with dyadic adjustment while their PTSD symptoms were not. LIMITATIONS: The cross-sectional data did not allow to identify directional or causal effects and DSO symptoms were not assessed with an ICD-specific instrument as such scales did not exist at the time of data collection. CONCLUSIONS: ICD-11 DSO symptoms seem to drive the transmission of posttraumatic stress among spouses to a more significant extent than PTSD symptoms. As DSO are also strongly implicated in decreased dyadic adjustment, they are valuable targets for couple therapy after one spouse experienced severe trauma, both in order to prevent interpersonal trauma transfer as well as to enhance dyadic adjustment

Associations between moral injury, PTSD clusters, and depression among Israeli veterans: a network approach

Background: Moral Injury (MI) is one of the adverse consequences of combat. Following exposure to potentially morally injurious events (PMIEs)––events perceived as violations of deep moral beliefs by oneself or trusted individuals––a significant minority of veterans could develop posttraumatic stress disorder (PTSD) and depression. Objective: The current study represents the first attempt to apply a network analysis model to examine an exploratory empirical conceptualization of a network of PMIEs during military service, post-traumatic stress disorder (PTSD) symptom clusters, depression, and combat exposure among Israel Defence Forces veterans. Method: A volunteer sample of 191 Israeli combat veterans were recruited during 2017, and completed validated self-report questionnaires tapping PMIEs, PTSD, and depression in a cross-sectional design study. A regularized Gaussian graphical model was estimated. Results: Network analysis revealed strong bridge associations between the PTSD nodes and most of the PMIEs nodes. The nodes of PMIE-betrayal and PTSD negative alterations in cognitions and mood (NACM) symptom cluster were found to have a bridging function between other PMIEs and PTSD. Depression was found to be connected to most of the PMIEs and PTSD nodes. Conclusions: The study’s findings offer an overview of the complex relationships between PMIEs and PTSD clusters among Israeli veterans. PMIEs––notably, betrayal-based experiences––are related to PTSD clusters directly and through depressive symptoms. Some possible mechanisms for the links between PMIEs and PTSD and the clinical implications related to specific interventions are discussed

The intergenerational sequelae of war captivity: the impact of a self-amplifying cycle of PTSD and attachment insecurities on offspring’s attachment orientations

Background: War captivity is one of the most severe human-made traumatic events which lead to self-amplifying cycle of post-traumatic stress disorder (PTSD) symptoms and attachment insecurities. Solid evidence in the literature pointed out on the intergenerational transmission of PTSD symptoms. However, no research has been conducted on the intergenerational transmission of attachment insecurities and the effect of the self-amplifying cycle among former prisoners of war (ex-POWs) and their offspring attachment insecurities. Objective: This research aims to explore the intergenerational impact of a self-amplifying cycle of PTSD and attachment insecurities among ex-POWs on their offspring’s attachment orientations. Method: We sampled dyads of Israeli ex-POWs of the Yom Kippur war and their adult offspring (ex-POW group) (n = 80) as well as dyads of Israeli veterans who fought in the Yom Kippur war, but were never held captive, and their adult offspring (control group) (n = 40). Veterans reported on PTSD severity and attachment orientations (anxiety, avoidance). Offspring reported on attachment orientations. We conducted (a) hierarchical regressions to predict offspring attachment orientations as a function of veterans’ attachment orientations, and (b) moderated mediation analyses examining the role of veterans’ PTSD in the intergenerational transmission of attachment orientations. Results: Ex-POWs’ attachment anxiety was associated with offspring’s reports of higher attachment anxiety and avoidance, and this intergenerational transmission of attachment was mediated by ex-POWs’ PTSD severity. These effects were not significant in the control group. Conclusions: Decades after the war end, the intergenerational sequelae of war captivity are evident by the impact of the self-amplifying cycle of PTSD and attachment insecurities among ex-POWs and their offspring’s attachment insecurities. Therefore, it is imperative for clinicians to recognize the intergenerational transmission and to focus not only on the trauma but also on the traumatized person’s attachment injuries and the shattering of core beliefs about the world, self, and others, in the context of attachment-based therapies

The Role of Parental Posttraumatic Stress, Marital Adjustment, and Dyadic Self-Disclosure in Intergenerational Transmission of Trauma: A Family System Approach

Research indicates that posttraumatic stress symptoms (PTSS) induced by war trauma may be transmitted to veterans' wives and offspring (secondary traumatic stress; STS). However, the interplay between family members' characteristics has not been accounted for in such processes. Taking a family systems perspective, we examine the contributions of fathers' PTSS, mothers' STS, marital adjustment, and self-disclosure of both parents to offspring's STS and test whether marital quality applies as a mechanism of parent-child transmission. Combat veterans and former prisoners of war (N = 123), their spouses, and adult offspring were investigated in a multiple-step mediation analysis. The results highlight the mother's crucial role in trauma transmission and suggest that strengthening the marital relationship may buffer the transmission of fathers' PTSS to offspring