Exposure to potentially morally injurious events, disruption in assumptive world, moral injury symptoms, and psychological distress among Israeli female veterans

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.

The impact of moral injury on suicide risk among recently discharged Israeli veterans: A longitudinal moderated mediation model of trauma-related guilt and self-forgiveness.

“…The results of this study also validated the indirect association between PMIE exposure and SIB via trauma-related guilt. Although studies among Israeli female veterans (Zerach & Levi-Belz, 2023) and male combatants (Zerach et al, 2023) documented the mediating role of guilt between PMIE exposure and psychological distress, this is the first longitudinal study to highlight chronological associations between exposure to transgressive acts and suicide risk. This effect might be explained by the unique time frame of the transition from military service to civilian life (Mobbs & Bonanno, 2018).…”

“…As Litz et al’s (2009) working model for MI suggests, veterans’ transgressive acts might be associated with suicide risk through a profound psychological dissonance associated with moral pain and MI outcomes of guilt and shame (Vermetten & Jetly, 2018). Indeed, a recent study found that disruption in the assumptive world and MI outcomes of guilt and shame mediated the link between PMIEs and psychological distress among Israeli female veterans (Zerach & Levi-Belz, 2023). Another recent study found that predeployment aggressiveness was significantly associated with PMIE-Betrayal, related to trauma-related guilt and shame, which, in turn, were associated with high levels of PTSD symptoms postdeployment (Zerach et al, 2023).…”

“Routine trauma”—Awareness of combat trauma in women combatants.

“…However, to date, most studies on the mental health consequences of military service in Israel, including those conducted by the Israel Defense Forces (IDF), have focused predominantly on men combat veterans or on comparisons between men and women veterans, with less research focusing particularly on women (Zerach, 2023). A recent exception is a study of Israeli women veterans that examined combat trauma and exposure to potentially morally injurious events during military service; that study revealed that women combat veterans reported higher levels of posttraumatic stress disorder (PTSD), versus noncombat veterans (Zerach, 2023; Zerach & Levi-Belz, 2023).…”

Constellations of posttraumatic stress symptoms and posttraumatic growth among Israeli female combat veterans: A latent profile analysis approach

“…Naturally, high exposure to military‐related experiences such as MST was associated with PTSD (Sumner et al, 2021). Moreover, exposure to combat events (Greenberg et al, 2021) and total potentially morally injurious events (PMIEs) were associated with PTSS (Zerach & Levi‐Belz, 2022b). However, exposure to MST was also associated with high PTG (Preston et al, 2023), and exposure to PMIEs perpetrated by oneself was associated with high PTG (Evans et al, 2018).…”

“…Military service exposes female combatants to substantial and diverse stressors and potentially traumatic events (PTEs; Danan et al, 2017). In addition to common exposure to war-related adversity (Lehavot et al, 2018), they might be exposed to military sexual trauma (Wilson, 2018), gender-based harassment (Fenwick et al, 2021), and serious ethical and moral dilemmas (Zerach & Levi-Belz, 2022b). Exposure to PTEs during military service might put female combatants at risk for long-term mental health disorders, the most common of which is posttraumatic stress disorder (PTSD; Dodds & Kiernan, 2019).…”