Background Moral injury has primarily been studied in combat veterans but might also affect healthcare workers (HCWs) due to the COVID-19 pandemic. Objective To compare patterns of potential moral injury (PMI) between post-9/11 military combat veterans and healthcare workers (HCWs) surveyed during the COVID-19 pandemic. Design Cross-sectional surveys of veterans (2015–2019) and HCWs (2020–2021) in the USA. Participants 618 military veterans who were deployed to a combat zone after September 11, 2001, and 2099 HCWs working in healthcare during the COVID-19 pandemic. Main Measures Other-induced PMI (disturbed by others’ immoral acts) and self-induced PMI (disturbed by having violated own morals) were the primary outcomes. Sociodemographic variables, combat/COVID-19 experience, depression, quality of life, and burnout were measured as correlates. Key Results 46.1% of post-9/11 veterans and 50.7% of HCWs endorsed other-induced PMI, whereas 24.1% of post-9/11 veterans and 18.2% of HCWs endorsed self-induced PMI. Different types of PMI were significantly associated with gender, race, enlisted vs. officer status, and post-battle traumatic experiences among veterans and with age, race, working in a high COVID-19–risk setting, and reported COVID-19 exposure among HCWs. Endorsing either type of PMI was associated with significantly higher depressive symptoms and worse quality of life in both samples and higher burnout among HCWs. Conclusions The potential for moral injury is relatively high among combat veterans and COVID-19 HCWs, with deleterious consequences for mental health and burnout. Demographic characteristics suggestive of less social empowerment may increase risk for moral injury. Longitudinal research among COVID-19 HCWs is needed. Moral injury prevention and intervention efforts for HCWs may benefit from consulting models used with veterans.

Anticipatory grief is the process associated with grieving the loss of loved ones in advance of their inevitable death. Because anticipatory grief has been associated with a variety of outcomes, risk factors for this condition deserve closer consideration. Fifty-seven family members of terminally ill, hospice-eligible veterans receiving palliative care services completed measures assessing psychosocial factors and conditions. Elevated anticipatory grief was found in families characterized by relational dependency, lower education, and poor grief-specific support, who also experienced discomfort with closeness and intimacy, neuroticism, spiritual crisis, and an inability to make sense of the loss. Thus, in this sample, anticipatory grief appears to be part of a cluster of factors and associated distress that call for early monitoring and possible intervention.

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Moral injury merits further study to clarify its identification, prevalence, assessment and intersection with psychosocial and psychiatric problems. The present study investigated the screening potential of the Brief Moral Injury Screen (BMIS) in a sample of post‐9/11 veterans (N = 315) and comparatively evaluated how this tool, the Moral Injury Events Scale (MIES), and the Moral Injury Questionnaire‐Military Version (MIQ‐M) relate to psychiatric diagnoses and mental illness symptom severity. Those who endorsed failing to prevent or doing something morally wrong had the highest symptomatology scores on measures of posttraumatic stress disorder, depression, suicidality, alcohol abuse and drug abuse, followed by those who reported solely witnessing a moral injury event. Posttraumatic stress disorder and depressive symptoms correlated most strongly with scores on the MIQ‐M; suicidality, alcohol abuse and drug abuse scores correlated most strongly with scores on the BMIS and MIQ‐M. Moral injury, as measured by three scales, was robustly correlated with worse outcomes on various symptom measures. The three scales appear to differentially predict mental illness symptomatology and diagnoses, with the BMIS predicting suicidality and alcohol and drug abuse as well as better than other measures.

Objectives: Theoretical support for the moral injury (MI) construct is mounting, yet empirical support has lagged behind. A conceptual model has been proposed, but studieshave not yet explored the constellation of symptoms within treatment-seeking Veterans. Methods: Veterans (N = 212) seeking trauma recovery services completed measures of potential MI symptoms that functioned as indicators in person-centered Latent Profile Analysis. Differences in exposure to potentially morally injurious experiences (pMIEs) were compared across profiles using logistic regression. Results: Three profiles emerged that varied by symptom severity, levels of trauma-related guilt, and levels of dispositional forgiveness. Exposure to pMIEs predicted membership in a class consistent with proposed MI symptomatology.Conclusions: Person-centered approaches are useful for identifying a distinct group of veterans whose trauma recovery may benefit from specifically targeting moral emotions, consistent with the emerging construct of MI . K E Y W O R D S guilt, moral injury, PTSD, trauma, Veterans J. Clin. Psychol. 2019;75:499-519.wileyonlinelibrary.com/journal/jclp

Many bereavement researchers focus on predicting and preventing complicated grief, a psychologically crippling, sometimes life-threatening response to loss that persists for lengthy periods, often with serious health consequences. Reviews of studies have identified specific risk factors (e.g., low social support, insecure attachment style) that predict high levels of complicated grief symptomatology. However, studies rarely investigate multiple risk factors in combination, and still more rarely trace factors observable during the end-of-life period and their predictive power for identifying intense grief in family members following the death. We therefore investigated several pre-loss risk factors for post-loss bereavement distress in 35 family members of Veterans who died of a terminal illness after receiving palliative care. Results revealed that being female, Caucasian, losing a spouse, and experiencing high anticipatory grief prior to the death, all predicted high levels of grief 6 to 10 weeks following the death. Moreover, psychosocial factors such as being highly dependent upon the Veteran, displaying high neuroticism, reporting low levels of social support, and being unable to make sense of the prognosis or death predicted more intense post-loss grief reactions.

This chapter was coauthored by employees of the United States government as part of official duty and is considered to be in the public domain. Any views expressed herein do not necessarily represent the views of the United States government, and the authors' participation in the work is not meant to serve as an official endorsement.