The present study examined the degree to which morally injurious experiences (MIEs; i.e., atrocities of war, psychological consequences of war, and leadership failure/betrayal) and moral injury (i.e., guilt, shame, difficulties with forgiveness, and withdrawal associated with exposure to MIEs) were associated with symptoms of depression, anxiety, posttraumatic stress disorder (PTSD), suicidality, hazardous alcohol use, and drug abuse symptoms. In addition, we examined moral injury and PTSD symptoms as mediators of the association between MIEs and these outcomes (exploratory model). Participants (n = 244) were a predominantly veterans community-based military sample. Our primary model (i.e., single mediation model) revealed that moral injury mediated associations between two MIEs (i.e., atrocities of war and leadership failure/betrayal) and depressive symptoms, anxiety symptoms, hazardous alcohol use, and PTSD symptoms. However, our exploratory model (i.e., a dual simultaneous mediation model) revealed that moral injury was not significantly associated with any health outcomes after controlling for the effects of MIE dimensions and PTSD symptoms. Within this model, PTSD symptoms significantly mediated the effects of both atrocities of war MIEs and leadership failure/betrayal MIEs on depressive symptoms, anxiety symptoms, suicidality, and hazardous alcohol use. Findings provide preliminary support for moral injury as a mechanism linking exposure to MIEs to both mental health and hazardous alcohol use. Taken together, moral injury appears to be an important target for intervention among combat military personnel.

Moral injury (MI) results from perpetration of or exposure to distressing events, known as morally injurious events (MIEs), that challenge moral beliefs and values. Due to the type of involvement in recent military conflicts, many veterans report MIEs that may cause dissonance and, in turn, MI. Although two existing measures assess MIEs, neither currently assesses the defining characteristics of MI (i.e., guilt, shame, difficulty forgiving self and others, and withdrawal). The present study reports the initial psychometric test of a modified version (Robbins, Kelley, Hamrick, Bravo, & White, 2017) of the Moral Injury Questionnaire – Military version (MIQ-M; Currier, Holland, Drescher, & Foy, 2015) in a sample of 328 military personnel (e.g., veterans, National Guard/reservists, active duty members). The MIQ-M was modified to assess both MIEs and the defining characteristics of MI. Exploratory factor analyses suggested a three-factor model of MIEs consisting of Atrocities of war, Psychological consequences of war, and Leadership failure or betrayal. The modified MIQ-M factors were correlated with defining characteristics of MI. In addition, each MIE factor and associated defining characteristics of MI were positively correlated with symptoms of posttraumatic stress disorder, depression, and anxiety, as well as substance use. The modified MIQ-M is a reliable measure of MI that is comprised of three subscales that are associated with, but distinct from, mental health outcomes. Although findings are promising, further research evaluating the applicability of the modified MIQ-M in clinical settings is required to establish construct validity of the defining characteristics and secondary manifestations of MI.

Potentially morally injurious experiences (PMIEs) are events that may violate deeply held values or belief systems. Combat engagement places service members at a heightened risk for PMIE exposure. Exposure to PMIEs may elicit internal conflict between moral beliefs and experiences and, if unresolved, conflict may manifest as feelings of guilt, shame, and spiritual or existential crisis. Further, distress caused by these experiences may promote harmful behaviors (e.g., excessive alcohol use), which may serve as attempts to cope with PMIEs veterans have witnessed or participated in. The present study examined a sequential mediation model in which combat exposure was associated with alcohol use (i.e., alcohol consumption, dependence symptoms, and alcohol‐related problems) via PMIE exposure and spiritual injury (e.g., alienation from and/or anger towards respective higher power) in a community sample of 380 recent‐era combat veterans. Multiple‐group sequential mediation was then used to examine whether the model fit similarly across men and women. Exposure to PMIEs and spiritual injury sequentially mediated the association between combat and alcohol; higher levels of PMIE exposure and spiritual injury were associated with increased alcohol use, R2 = .17, f2 = 0.07. The multiple‐group model showed that these associations significantly varied between genders such that the mediation was only significant among men. The results indicated that PMIEs and spiritual injury were associated with increased alcohol use, but these associations differed as a function of gender. Future research is needed to refine our understanding of moral and spiritual injury and explore possible risk and protective factors.

Moral injury is a unique type of trauma characterized by guilt and shame that may develop after acting inconsistently with one's moral values or observing moral violations by trusted individuals. According to the moral injury syndrome model, exposure to potentially morally injurious events (pMIEs-e.g., killing combatants or civilians) statistically predicts the development of proposed moral injury symptoms. Moral injury's core symptoms (e.g., guilt and loss of meaning) are further hypothesized to mediate relationships between pMIEs and secondary symptoms (e.g., depression, anxiety, and posttraumatic stress disorder symptoms). To empirically evaluate these propositions, the relationships between exposure to pMIEs, core symptoms, and secondary symptoms were examined in a community sample of combat veterans (N ϭ 72). pMIE exposure was statistically associated with all proposed moral injury symptoms. Furthermore, the relationships between pMIE exposure and secondary symptoms were all mediated by core symptoms. Results highlight guilt's centrality in moral injury.

Moral injury and post-traumatic stress disorder are argued to be distinct yet related constructs. However, few studies have evaluated the factors distinguishing moral injury from PTSD. The present study sought to extend the work of Bryan et al. (2018) by differentiating the symptomology of moral injury and PTSD and their associations with suicidal behaviors among combat veterans. The study evaluated data from 129 combat veterans exposed to potentially morally injurious events. Exploratory structural equation modeling evaluated a measurement and structural model. Results revealed a four-factor solution, with the relevant factors being PTSD symptoms, guilt/shame, psychiatric comorbidities, and meaning in life. Guilt/shame and psychiatric comorbidities had significant positive effects on suicidal behaviors. The present findings suggest that combat veterans have a complex, dimensional response to combat trauma and pMIE exposure. These results diverged from previous research to suggest that moral injury symptoms may not constitute a single factor but rather a multifaceted constellation of symptoms. The present study also provided evidence that moral injury symptoms are both unique and overlapping with PTSD symptoms. Suicidal behaviors are a major area of concern among veterans, and the findings here implicate guilt/shame and psychiatric comorbidities as related to these suicidal behaviors.