Moral injury is a relatively new psychological syndrome characterized by profound emotional, cognitive, and social pain following perceived moral violations. Though often overlapping, moral violations can involve either the perpetration of a moral transgression (via action or inaction) or the experience of a moral betrayal by a trusted other. In each case, symptoms of moral injury may include guilt, shame, anger, loss of trust and meaning, and social withdrawal. To date, the study of moral injury has remained nearly exclusive to the military arena. In turn, the aim of this thesis is to highlight the relevance of moral injury to other populations vulnerable to its effects. These include: 1) justice-involved individuals found Not Criminally Responsible on Account of Mental Disorder who may experience moral injury after regaining insight into their offending behaviour; and 2) Public Safety Personnel who are often exposed to morally ambiguous situations while under high levels of social responsibility. To appreciate the impact of moral injury for these populations, adequate tools must first be developed to measure and assess it. The three studies included in this dissertation outline the key steps to instrument development using a mixed-method approach: first, a qualitative investigation with justice-involved individuals explores the unique emotional consequences following a criminal offence that will inform subsequent phases of instrument development; second, quantitative inquiries are taken to construct, evaluate, and employ a new moral injury assessment for Public Safety Personnel to uncover important causes and consequences of moral injury in this group. This dissertation serves as a strong indicator that moral injury is a unique and costly health outcome relevant across societal groups. / Dissertation / Doctor of Philosophy (PhD) / Moral injury is a new psychological syndrome developed to understand an individual’s response to a moral trauma. As with other traumatic stress disorders, some people may develop a moral injury after experiencing a situation or event that violates deeply held moral standards. These morally injurious events may be moral violations perpetrated by the individual and result in deep feelings of shame and guilt, or may be moral betrayals by a trusted other and result in feelings of anger and loss of trust. To better understand the causes, symptoms, and consequences of moral injury, we must first develop tools to measure and assess it. This thesis outlines the key steps involved in developing new moral injury assessments in two groups who have an elevated risk of experiencing morally injurious events and so may be more likely to develop a moral injury: justice-involved individuals found Not Criminally Responsible and Public Safety Personnel.

The term “moral injury” has recently been introduced to describe psychopathology resulting from perpetrating or bearing witness to an event that transgresses deeply held moral beliefs, typically in relation to military service. Two studies examined relations between potentially morally injurious events (PMIEs) during military service, self-conscious emotions, and negative mental health outcomes. The potential moderating contributions of social support and psychopathic personality traits on these relations were also assessed. A subset of 40 of the 501 veterans who completed a detailed on-line survey was also interviewed to gain a more thorough understanding of individual experiences. Veterans who had experienced higher numbers of PMIEs were significantly more likely to experience depression symptoms and suicidal ideation, as well as guilt and shame related to their military service, but high levels of social support decreased the likelihood of negative mental health outcomes and subsequent guilt and shame; psychopathic personality traits did not moderate these relations. Qualitative analysis of the interviews confirmed that social support plays a key role in the prevention of moral injury-related symptoms. Social support was crucial to reintegration after deployment for many veterans. Results indicate that adequate social support following PMIEs may reduce the likelihood of psychopathology. Implications of this study and future directions are discussed.

My thesis will begin to examine alcoholism and recovery through the lens of moral injury, especially in relationship to the use of spirituality language and the often-invoked correlation between spirituality and sobriety. Through a literature review and interviews with abstaining alcoholics, I will unpack some of the implications of considering alcoholism through the lens of moral injury and begin to frame and examine some of the questions inherent in that consideration. By so doing, I hope to offer a fresh look into those aspects of recovery that fall within the Religious Studies purview.

The First Amendment gives U.S. citizens a Hohfeldian legal immunity that disables Congress from removing citizens’ legal liberty to criticize the government. Any attempt by Congress to remove this liberty would fail, but such an attempt would still wrong citizens. The familiar concept of claim-violation does not fully account for this wrong. Claims name actions that ought not be performed and are violated when those actions are performed. Immunities names actions that cannot be performed. Congress would wrong citizens not by doing something it ought not do but by attempting and failing to do something it cannot do. Using elements of Jean Hampton’s expressive theory of punishment, I analyze Congress’ attempt (and other similar acts) as an expressive act that denies the existence of immunities. Congress’ immunity-“contradiction” would wrong U.S. citizens by denying the value that generates the immunity, by causing damage to the acknowledgement of the citizens’ value, and by threatening the existence of the immunity.

Previous research on the symptoms of Moral Injury suggests that it commonly results in clinical impairment (Drescher et al., 2011). Recent models have suggested that Acceptance and Meaning-Making may moderate the relationship between Moral Injury and Posttraumatic Growth (Blackie et al., 2016). However, Meaning-Making and Acceptance have yet to be examined in a population with Moral Injury. Data were collected from 120 participants from Amazon Mechanical Turk (MTurk) online marketplace. Participation was restricted to U.S. military and veterans who have experienced a traumatic event. Participants completed a demographics questionnaire (Seidler, 2016), the Posttraumatic Checklist (PCL; Weathers et al., 2013), the Moral Injury Questionnaire-Military Version (MIQ-M; Currier, Holland, Drescher, & Foy, 2013), the Integration of Stressful Live Events Scale (ISLES; Holland, Currier, Coleman, & Neimeyer, 2010), the Acceptance Subscale of the Multidimensional Psychological Flexibility Inventory (MPFI; Rolffs, Rogge, & Wilson, 2016), and The Posttraumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1995). This study tested the following research hypotheses: 1) Scores for Meaning-Making and Acceptance will significantly and positively predict scores for Posttraumatic Growth in a sample population with PTSD; 2) Scores for Meaning-Making and Acceptance will moderate the relationship between measures of Moral Injury and Posttraumatic Growth, with higher scores of Meaning-Making and Acceptance resulting in higher scores of Posttraumatic Growth and lower scores of Meaning-Making and Acceptance resulting in lower scores of Posttraumatic Growth; 3) Three distinct groups of people can be high and low scores for Moral Injury and symptoms of PTSD. In contrast to the hypothesis, both Acceptance of negative emotions and Meaning-Making demonstrated direct effects but did not moderate the relation between Moral Injury and Posttraumatic Growth. Acceptance also appears to partially mediate the relationship between Moral Injury and PTG. The results of the cluster analysis identified three groups of participants based primarily on scores for Moral Injury, namely those with high, low and moderate scores. Participants with high Moral Injury scores had high scores for PTSD symptoms. The other two groups had moderate PTSD symptom scores. Implications of findings and suggestions for future research are discussed.

Initial research on moral injury has shown the construct to be associated with many negative mental health outcomes such as depression, suicidal ideation, reduced sense of belonging, anxiety, anger, and spiritual distress. In addition, moral injury among service members has also been shown to be related to experiences of interpersonal violence occurring pre-deployment. Given that social support has consistently been found to play a key role in moderating the relationship between experiences of interpersonal violence and stress and trauma related symptoms and disorders, this study will be the first to explore the relationship between experiences of interpersonal violence and moral injury, and the moderating role of social support. This study will use stepwise regression analysis to examine secondary data collected from 935 U.S. military personnel primarily from the Army National Guard. / MS / Research has found that bearing witness to or engaging in an act that goes against an individual’s own moral beliefs can lead to many negative mental health outcomes such as depression, suicidal ideation, reduced sense of belonging, anxiety, anger, and spiritual distress. Researchers and clinicians have developed the term moral injury to describe the moral distress and individual may experience after they are exposed to a morally injurious event. Moral injury among service members has also been shown to be related to traumatic experiences involving intentional harm of one individual by another, also known as interpersonal violence. Given that social support has consistently been found to play a key role in decreasing the relationship between experiences of interpersonal violence and stress and trauma related symptoms and disorders, this study will be the first to explore the relationship between experiences of interpersonal violence and moral injury, and the diminishing role of social support.

Combat medics’ personal identities can become indistinguishable from the professional responsibility they have to provide care to a particular group, as a result of the official training and unofficial acculturation they receive in the military. This constructs an intensified moral world in which medics live for a time and sets the stage for a specific kind of moral experience in combat, one grounded in a sense of personal responsibility for the physical well-being of their comrades. When combat medics are unable to fulfill their professional role, this can cause a distinct form of moral trauma, because they have also failed to fulfill a personal sense of purpose.

While there is considerable research linking trauma to psychological distress, such as posttraumatic stress disorder (PTSD), among military populations, some service members may develop other variants of psychological difficulties following exposure to traumatic life events. For example, moral injury, a more recently studied outcome within the field of trauma, is conceptualized to occur when a person perceives their response to a morally challenging situation as a transgression that may lead to an incongruence with their morals producing moral emotions (i.e., shame, guilt, and anxiety; Litz et al., 2009). The current study investigated the role of self-compassion in the relationship between moral injury and psychological distress (i.e., PTSD and depression) among a sample of 216 military veterans recruited from TurkPrime online panels. Among these military veterans, a conditional process analysis of our moderated mediation model suggests an indirect effect of moral injury predicting depression symptoms through guilt, Index = 1.469, SE = .460, 95% CI [.602, 2.409] and shame, Index = -.803, SE = .346, 95% CI [-1.552, -.161] was conditioned on different levels of self-compassion. Findings are expected to have important implications for treatment conceptualization for military populations.

Moral injury (MI) among military personnel is a harmful condition caused by perpetrating, failing to prevent, or witnessing atrocities that violate one's deeply held morals or values. The current study built on the existing literature by exploring predictors of MI, specifically trait self-forgiveness (TSF), state self-forgiveness (SSF), perceived social support (PSS), and causal attributions (CA) following potentially morally injurious experiences (PMIEs) in service members and veterans. Participants were 92 U.S. military service members and veterans. The main findings were that TSF and PSS were both significantly negatively associated with MI in bivariate and multivariate analyses. Further, TSF and PSS were examined as potential moderators of the relationship between PMIEs and MI, but these moderation analyses were not significant. Given that some studies provide evidence for different symptom profiles between categories of PMIEs (i.e., PMIE-Self, PMIE-Other, and PMIE-Betrayal), the relationship between the different categories and TSF were explored. Of the three PMIE types, only PMIE-Betrayal was a significant negative predictor of TSF. Finally, CA was explored as a potential mediator of the relationship between TSF and MI outcomes, but this mediation analysis was not significant. Limitations, directions for future research, and implications for clinical practice are included for discussion.

Background: For decades, researchers have been striving to better understand the complex mix of factors underlying post-combat mental illness, in the hope of enabling better outcomes for military personnel. This study focuses on investigating the behavior and possible interaction of two risk factors for poor mental health post-deployment to a combat mission: adverse childhood experience (ACE) and deployment-related stressful experience (DRSE). Methods: A longitudinal dataset linking data from 3302 military personnel at recruitment to data collected post-deployment to Canada’s mission in Afghanistan was analysed, using novel scoring systems for exposure classification. Results: Significant ACE-DRSE interaction terms were found in relation to SF-36 MCS, depression and suicidal ideation: the negative effect DRSE had on mental health outcomes was amplified as ACE levels increased. Conclusion: Individuals with a history of childhood adversity are more susceptible to the negative mental health impacts of stressful experiences during deployment to a combat zone.