exploring the maladaptive cognitions of moral injury

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Exploring the Maladaptive Cognitions of Moral Injury Exploring the Maladaptive Cognitions of Moral Injury

Rachel L. Martin University of Southern Mississippi

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EXPLORING THE MALADAPTIVE COGNITIONS OF MORAL INJURY

by

Rachel Lynn Martin

A Dissertation

Submitted to the Graduate School,

the College of Arts and Sciences

and the School of Psychology

at The University of Southern Mississippi

in Partial Fulfillment of the Requirements

for the Degree of Doctor of Philosophy

Approved by:

Dr. Daniel Capron, Committee Chair

Dr. Michael Anestis

Dr. Randolph Arnau

Dr. Richard Mohn

August 2020

COPYRIGHT BY

Rachel Lynn Martin

2020

Published by the Graduate School

iii

ABSTRACT

Moral injury and Post-Traumatic Stress Disorder (PTSD) are two prominent mental

health problems that affect military personnel. Moral injury results when the individual is

exposed to a situation or event that violates their moral code; however, PTSD results

when there is a substantial threat of harm. Moral injury is a relatively new construct

within the literature with research starting in the late 2000s. Although distorted

cognitions are core components of PTSD symptomatology, there has been no research of

cognitions in moral injury. The current study sought to differentiate PTSD and moral

injury using the specific maladaptive cognitions associated with trauma (i.e., self-worth

and judgement, threat of harm, forgiveness of the situation reliability, trustworthiness of

others, forgiveness of others, forgiveness of self, and atonement). Participants (N=253)

were previously deployed military personnel, 90.1% of whom experienced foreign

deployment(s). Results indicated that moral injury was defined by atonement, self-worth

and judgement, reliability and trustworthiness of others, and forgiveness of others while

PTSD was defined by threat of harm and forgiveness of the situation. Forgiveness of self

was not associated with moral injury nor PTSD. The current investigation provides

further empirical support to identify moral injury as a construct distinct from PTSD.

Key Words: Moral Injury, PTSD, Maladaptive Cognitions

iv

ACKNOWLEDGMENTS

I would like to thank my mentor, Dr. Daniel Capron, for his guidance and support

throughout graduate school. I would also like to thank my committee members, Dr.

Michael Anestis, Dr. Randolph Arnau, and Dr. Richard Mohn for contributing their

expertise to this project. Finally, I would like to thank the Military Suicide Research

Consortium for funding this project. This work was in part supported by the Military

Suicide Research Consortium (MSRC), an effort supported by the Office of the Assistant

Secretary of Defense for Health Affairs under Award No. (W81XWH-16-2-0004).

Opinions, interpretations, conclusions and recommendations are those of the author and

are not necessarily endorsed by the MSRC or the Department of Defense."

v

DEDICATION

I would like to dedicate this document to my family for their continued support

throughout my graduate school career. Thank you Mom, Dad, Leslie, and Randy for your

encouragement as I worked toward my Ph.D. Finally, thank you Brian for your love and

patience while I fulfilled my dream of becoming a Ph.D. I could not ask for a better

partner.

vi

TABLE OF CONTENTS

ABSTRACT ....................................................................................................................... iii

ACKNOWLEDGMENTS ................................................................................................. iv

DEDICATION .................................................................................................................... v

LIST OF TABLES ............................................................................................................. ix

LIST OF ILLUSTRATIONS .............................................................................................. x

LIST OF ABBREVIATIONS ............................................................................................ xi

CHAPTER I - INTRODUCTION ...................................................................................... 1

Moral Injury .................................................................................................................... 2

Maladaptive Cognitions Related to Trauma and Moral Injury ....................................... 3

Treatment ........................................................................................................................ 6

Proposed Study ............................................................................................................... 8

Hypotheses .................................................................................................................. 9

Exploratory Hypothesis .............................................................................................. 9

CHAPTER II - METHODS .............................................................................................. 11

Participants and Procedure ............................................................................................ 11

Measures ....................................................................................................................... 14

Eligibility .................................................................................................................. 14

vii

Life Events Checklist for DSM-5 ......................................................................... 14

Moral Injury Events Scale .................................................................................... 14

Post-Traumatic Stress Disorder Symptom Checklist ............................................ 15

Observed Variables ................................................................................................... 15

Posttraumatic Maladaptive Beliefs Scale .............................................................. 15

Heartland Forgiveness Scale ................................................................................. 16

Deployment-Related Events Atonement Measure ................................................ 16

Data Analytic Procedure ............................................................................................... 17

Power Analysis ......................................................................................................... 19

Model Fit Indices ...................................................................................................... 19

Model Modification and Alternative Model ............................................................. 20

CHAPTER III - RESULTS ............................................................................................... 22

Original Model .......................................................................................................... 24

Model #2 ................................................................................................................... 26

Model #3 ................................................................................................................... 27

Model #4 ................................................................................................................... 29

Model #5 ................................................................................................................... 31

Alternative Model ..................................................................................................... 33

CHAPTER IV – DISCUSSION........................................................................................ 37

Implications............................................................................................................... 42

viii

Theoretical ............................................................................................................ 42

Clinical .................................................................................................................. 42

Limitations ................................................................................................................ 43

Strengths ................................................................................................................... 44

Future Research ........................................................................................................ 44

Conclusions ............................................................................................................... 45

APPENDIX A ................................................................................................................... 46

REFERENCES ................................................................................................................. 47

ix

LIST OF TABLES

Table 1 Participant demographic information .................................................................. 11

Table 2 Atonement Questionnaire .................................................................................... 17

Table 3 Descriptive statistics and correlations for variables utilized in the primary

analyses ............................................................................................................................. 18

Table 4 Goodness-of-Fit Indices for the proposed models ............................................... 23

Table 5 Table of standardized model results for original proposed model ....................... 26

Table 6 Table of standardized model results for model 2 ................................................. 27




Table 10 Table of standardized model results for alternative model ................................ 35

x

LIST OF ILLUSTRATIONS

Figure 1. Hypothesized Associations .................................................................................. 9

Figure 2. Participant flow ................................................................................................. 13

Figure 3. Original model with significant pathways and standardized estimates (STDYX)

........................................................................................................................................... 25

Figure 4. Model 5 with significant pathways and standardized estimates (STDYX) ....... 33

Figure 5. Alternative model with significant pathways and standardized estimates

(STDYX)........................................................................................................................... 36

xi

LIST OF ABBREVIATIONS

AD Adaptive Disclosure

AIC Akaike Information Criteria

BIC Bayesian Information Criteria

CFA Confirmatory Factor Analysis

CFI Comparative Fit Index

CPT Cognitive Processing Therapy

DREAM Deployment-Related Events Atonement

Measure

EBTs Evidence-Based Treatments

HFS Heartland Forgiveness Scale

LEC Life-Events Checklist

MIES Moral Injury Events Scale

OEF Operation Enduring Freedom

OIF Operation Iraqi Freedom

PCL-5 Post-Traumatic Stress Disorder Symptom

Checklist

PE Prolonged Exposure

PMBS Posttraumatic Maladaptive Beliefs Scale

PTSD Post-Traumatic Stress Disorder

RMSEA Root Mean Square Error of Approximation

SABIC Sample-Size Adjusted BIC

SEM Structural Equation Modeling

xii

SRMR Standardized Root Mean Square Residual

TLI Ticker-Lewis Index

TrIGER Trauma Informed Guilt Reduction Therapy

1

CHAPTER I - INTRODUCTION

Trauma-related mental health problems have become a major public health

concern. The number of Iraq and Afghanistan conflict veterans seeking treatment for

PTSD is increasing (Institute of Medicine, 2014). PTSD prevalence rate amongst

veterans from the conflicts in Iraq and Afghanistan is estimated to be 23% (Fulton et al.,

2015). The prevalence rate of PTSD from the Iraq and Afghanistan conflicts is higher

than that of previous conflicts including Vietnam (Dohrenwend et al., 2006; Kulka et al.,

1990) and Persian Gulf (Kang, Natelson, Mahan, Lee, & Murphy, 2003; Toomey et al.,

2007).

For American forces, the conflicts in Iraq and Afghanistan provide unique

challenges that affect mental health after deployment. First, Operation Enduring Freedom

(OEF) and Operation Iraqi Freedom (OIF) are the most continued ground combat

missions since the Vietnam conflict (Friedman, 2005). Second, OEF and OIF are distinct

from previous conflicts due to urban-style warfare with roadside improvised explosive

devices being frequently used (Friedman, 2005; Reisman, 2016). Third, soldiers are

experiencing multiple tours of duty, at higher rates than in previous conflicts (Hoge et al.,

2004; Kinney, 2012; Seal et al., 2007). Finally, there has been an increase in the number

of wounded soldier’s surviving battle with approximately 90% of soldiers surviving

(Reisman, 2016). Soldier’s survival is primarily due to advances in technology for body

armor/combat medicine and the ability to quickly evacuate injured soldiers (Carlock,

2007; Gawande, 2004; Reisman, 2016). Although the increase in protective gear allows

for more soldiers to physically survive, they may return with psychological trauma.

2

Moral Injury

Moral injury results when the individual is exposed to a situation or event that

violates their moral code (Litz et al., 2009). Moral injury is defined as events in which an

individual either perpetuates, fails to prevent, bears witness to, or learns about actions

that contradict core moral beliefs (Litz et al., 2009). Moral injury is a social-cognitive

variable, incorporating the individual’s core beliefs as well as maladaptive beliefs about

the trauma. Recently, a moral injury syndrome was hypothesized to assist in empirical

study and theoretical distinction from PTSD (Jinkerson, 2016). To be classified as moral

injury, individuals must have experienced an event that violates their moral beliefs,

experience guilt, and two additional symptoms (e.g., shame, spiritual/existential conflict,

loss of trust in self or others, depression, anxiety, anger, suicidality, or social problems;

Jinkerson, 2016). Although the proposed moral injury syndrome provides distinct criteria,

it does not acknowledge the cognitive component of moral injury.

Moral injury may result from traumatic events; however, its unique presentation

differentiates it from PTSD. Although moral injury and PTSD may both develop after a

traumatic event, their etiologies differ in which moral injury results from moral danger

and PTSD results from mortal danger (Battles et al., 2018). PTSD is marked as a

physiological disorder including hyperarousal of threat response and avoidance (Litz et

al., 2016). Conversely, moral injury develops through internal conflict rather than

physiological pain (MacNair, 2002; Marx et al., 2010). Moral injury has been identified

as a potential variable in the understanding of military PTSD (Bryan et al., 2018).

Additionally, veterans who question their moral integrity during battle identify with

emotions such as alienation, loneliness, and abandonment (Doka, 2002; Fiala, 2008;

3

Harvey, 2002; Kauffmann, 2002; Shay 1994). Researchers have sought to differentiate

the symptomatology of moral injury and PTSD, primarily through examination of

emotions and behavioral changes. Bryan and colleagues identified guilt and shame as

components of moral injury not within PTSD (Bryan et al., 2018); however, their

research did not examine differences pertaining to maladaptive cognitions. As such,

future research should seek to differentiate moral injury and PTSD through maladaptive

cognitions.

Maladaptive Cognitions Related to Trauma and Moral Injury

Previous literature on information processing has identified how traumatic events

are encoded and processed differently than ordinary events (Foa & Kozak, 1986;

Horowitz, 1976). Specifically, information processing models of trauma posit that

following trauma exposure, individuals can develop biased patterns of interpreting new

information. These biases can affect how individuals perceive the world around them

(e.g., every-day situations as threatening or constant vigilance) or maintenance of PTSD

symptoms (Scher, Suvak, & Resick, 2017; Vogt, Shipherd, & Resick, 2012). The biases

resulting from trauma assist in interpretation and response to situations (Beck, Rush,

Shaw, & Emery, 1979). Therefore, maladaptive cognitions resulting from trauma can

affect future behaviors and beliefs about daily life (Resick & Schnicke, 1992, 1993;

Sobel, Resick, & Rabalais, 2009).

Distorted cognitions specific to the traumatic event and overall view of the world

are core components of PTSD symptomatology (APA, 2013; Brewin, 2007; Ehlers &

Clark, 2000). Due to the importance of distorted cognitions within PTSD, researchers

have examined distortions focusing on safety, esteem, control, trust, and intimacy (Foa,

4

Ehlers, Clark, Tolin, & Orsillo, 1999; Kaysen, Scher, Mastnak, & Resick, 2005;

Messman-Moore & Resick, 2002; Owens & Chard, 2001; Owens, Pike, & Chard, 2001;

Wenninger & Ehlers, 1998). These maladaptive cognitions have been examined across

domains such as self, others, and world (Herman, 1992; Janoff-Bulman, 1992).

Furthermore, cognitive change may be a mechanism in treatment of PTSD (Scher et al.,

2017), with changes in cognitions serving as predictors of changes in PTSD symptoms

(Ehlers et al., 1998; Foa & Rauch, 2004; Moser, Cahill, & Foa, 2010; Sobel, Resick, &

Rabalis, 2009). Although these maladaptive cognitions have been examined within the

context of PTSD, little is known about how they affect moral injury.

Cognitions are central to development of morality (Gibbs, 2003; Hoffman, 2001;

Kohlberg, 1984) and therefore moral injury. When moral injury occurs, individuals may

experience uniquely distorted cognitions. Litz and colleagues suggested that after a

potentially morally injurious event, there would be conflict with attributions such as a just

world, self-esteem, and belief in forgivability (Litz et al., 2009; Jinkerson, 2016). Moral

injury comprises cognitive conflicts and maladaptive cognitions. Furthermore, Litz and

colleagues posited that individuals may internalize these attributions to a belief that they

are unforgivable (Litz et al., 2009; Jinkerson, 2016). Although these maladaptive

cognitions have been theorized, there is a lack of empirical testing. If moral injury is a

social-cognitive variable, half of its etiology is unknown.

The Posttraumatic Maladaptive Beliefs Scale (PMBS; Vogt et al., 2012) is a brief

measure of cognitions examining the individual’s beliefs about current life circumstances

following exposure to trauma. The PMBS examines general, instead of trauma-specific,

distorted cognitions that affect functioning after a traumatic event (Vogt et al., 2012).

5

Specifically, the scale measures threat of harm, self-worth/judgment, and

reliability/trustworthiness of others. Previous research using the PMBS indicated a

significant association between each subscale and PTSD severity score (Scher et al.,

2017); however, there is no research examining if the PMBS subscales are associated

with moral injury. The PMBS may assist in differentiating moral injury from PTSD by

examining their associations with specific subscales. Since PTSD and trauma-related

disorders result from disturbances in processing events (Foa & Kozak, 1986; Rachman,

1980), identifying the maladaptive cognitions associated with moral injury can assist with

understanding the underlying cause of distress. Furthermore, maladaptive cognitions

about the trauma maintain PTSD symptoms (Foa, Ehlers, Clark, & Tolin, 1999). If the

results of the current investigation are consistent with the hypotheses and provide support

to separate posttraumatic maladaptive cognitions as either PTSD or moral injury related,

treatment of moral injury may be improved.

Another maladaptive cognition that may be prevalent in moral injury rather than

PTSD is lack of self-forgiveness. Self-forgiveness has been defined as “…the act of

generosity and kindness toward the self following self-perceived inappropriate action”

(Wohl, DeShea, & Wahkenney, 2008, p.2). Individuals who are low on self-forgiveness

perceive their actions to be reprehensible, even if others do not (Bryan et al., 2015). This

disconnect can lead to psychological distress, primarily through guilt or regret. Bryan and

colleagues (2015) identified self-forgiveness as factor that can differentiate suicide

attempters from ideators; however, self-forgiveness did not moderate the association

between posttraumatic stress and suicidal ideation or suicide attempt. Although the

authors did not find self-forgiveness to be a moderator of trauma exposure and general

6

posttraumatic stress, it may play an important role in moral injury. For individuals with

moral injury, self-forgiveness of actions against core beliefs may be more difficult than

self-forgiveness of a traumatic event. Understanding the differences between self-

forgiveness in PTSD and moral injury may help modify treatment.

Another maladaptive cognition that may assist in differentiating moral injury from

PTSD is atonement. Atonement, the belief that individuals need to atone for their actions,

may be an additional maladaptive cognition specifically associated with moral injury.

Nash (2017) identified “damaged concept of the world” as a component of moral injury.

He suggested that individuals with moral injury may “give or seek amends” to treat this

aspect of moral injury. If there is an untreated desire for atonement, it may lead to

internal conflict. Understanding the distorted cognitions associated with atonement for

transgressions done during service may be a key component to treatment of moral injury

not included in treatments of PTSD. Currently, there is limited research examining how

atonement effects mental health treatment. A major reason for the limited extant research

is the lack of reliable measures to examine atonement. To examine atonement-related

cognitions, the current study will create a new measure based on extant literature, named

the Deployment-Related Events Atonement Measure.

Treatment

Evidence-based treatments (EBTs) of PTSD are insufficient for treatment of

moral injury (Steenkamp et al., 2013; Maguen & Burkman, 2013). Treatment of moral

injury is necessary due to its association with psychopathology (i.e., anxiety, depressive,

and alcohol use disorders), suicidal ideation, and suicide attempts (Griffin et al., 2019;

Jinkerson & Battles, 2018; Levi-Belz & Zerach, 2018; Wisco et al., 2017). Furthermore,

7

amongst OEF marines, exposure to morally injurious events differentiated participants

who presented with low, partial, and full PTSD symptoms, in which individuals who had

higher exposure had more PTSD symptoms (Litz, 2017). It has been posited that there are

two main reasons why the EBTs for PTSD (i.e., Cognitive Processing Therapy [CPT] and

Prolonged Exposure [PE]) are not adequate for moral injury treatment (Steenkamp, Nash,

Lebowitz, & Litz, 2013). First, the treatments for PTSD were created when PTSD was

theorized to be a fear-based disorder and rely on habituation to decrease symptoms (Gray

et al., 2012; Litz et al., 2016; Steenkamp et al., 2013). Understanding the cognitive

component of moral injury may be crucial to developing effective treatments to address

subsequent psychopathology.

Although there are no independent treatments for moral injury, there have been

preliminary results from adjunct treatments addressing specific components of moral

injury. Maguen and colleagues (2017) adapted a cognitive-behavioral therapy framework

to treat individuals who endorsed distress regarding killing during war. The treatment

was developed to supplement current treatments of PTSD (i.e., CPT and PE). Within the

pilot study, participants were individuals who had already received EBTs for PTSD and

were still experiencing emotional distress. Killing during war is a traumatic event which

could lead to moral injury; however, moral injury contains additional constructs such as

witnessing others’ transgressions and betrayal. Further understanding the cognitive aspect

of moral injury may allow for continued development of this treatment to address all

components.

Treatment of moral injury has focused on emotions and self-forgiveness.

Recently, Trauma Informed Guilt Reduction Therapy (TrIGER): Treating Guilt and

8

Shame Resulting from Trauma and Moral Injury was introduced as a treatment for moral

injury (Normal et al., 2019). Within this transdiagnostic therapy, the clinician and client

examine factors including posttraumatic guilt and shame within moral injury.

Additionally, adaptive disclosure (AD), an exposure-based therapy, incorporates military

experiences into treatment (Steenkamp et al., 2011). AD is implemented in conjunction

with EBTs and addresses moral injury through a dialogue about forgiveness and

compassion about the transgression.

Overall, there are emerging treatments attempting to help individuals who

experience moral injury. Although these treatments focus on decreasing the core concepts

of moral injury (i.e., guilt and shame), they fail to recognize distorted cognitions specific

to moral injury. This may be due to the lack of research on this topic. Further

understanding the distorted cognitions related to moral injury may assist in expanding the

current treatments to address all facets of moral injury.

Proposed Study

Previous research has identified emotional and physiological differences between

moral injury and PTSD and hypothesized cognitive distortions related to moral injury.

The current study seeks to build upon this literature base by further examining

differences of maladaptive cognitions between moral injury and PTSD. Given the

previous literature examining maladaptive cognitions associated with PTSD and moral

injury, the current study examined how to differentiate PTSD and moral injury using the

specific cognitions associated with these variables (i.e., self-worth and judgement, threat

of harm, forgiveness of the situation reliability, trustworthiness of others, forgiveness of

others, forgiveness of self, and atonement). To address this, confirmatory factor analysis

9

(CFA) and structural equation modeling (SEM) were used to test the association between

maladaptive cognitions and either moral injury or PTSD.

Hypotheses

The first hypothesis was that moral injury will have five distinct maladaptive

cognition factor loadings (i.e., self-worth and judgment, reliability and trustworthiness of

others, forgiveness of others, forgiveness of self, and atonement). The second hypothesis

is that PTSD will have two factor loadings (i.e., threat of harm and forgiveness of the

situation). A visual representation of the primary hypotheses can be found in Figure 1.

Figure 1. Hypothesized Associations

Exploratory Hypothesis

In addition to two primary hypotheses, there was an exploratory hypothesis. The

exploratory hypothesis was that the Deployment-Related Events Atonement Measure will

demonstrate acceptable alpha coefficient (>.69) according to the Cronbach rating

system (Cronbach, 1951). Alpha coefficients indicate internal consistency, which is

10

necessary for future use. Currently, there is a lack of empirically validated measures of

deployment-related atonement. The DREAM questionnaire was created for this study by

utilizing the definition of atonement and previous literature on how individuals with

moral injury may seek amends (Nash, 2017). The questionnaire created for this study

may provide foundational data for future studies to examine deployment related

atonement cognitions.

11

CHAPTER II - METHODS

Participants and Procedure

A total of 3,954 potential participants interacted with the survey link with 253

individuals meeting criteria for to be included in analyses. Participants (N=253) were

military personnel who have been previously deployed. An overwhelming majority

(90.1%) of the participants indicated that they experienced foreign deployment(s).

Participant demographics can be found in Table 1.

Table 1 Participant demographic information

Sample Size 253

Age

Mean (SD) 48.10 (15.94)

Sex

Male (female) 77.1% (22.9%)

Race

White 78.7%

African American 11.9%

Hispanic/Latinx 4.3%

Asian/Pacific Islander 3.2%

Native American 1.6%

Other 0.4%

Marital Status

Married 66.8%

12

Table 1 (continued)

Never Married 17.4%

Separated 2.4%

Divorced 11.1%

Widowed and not remarried 2.4.%

Military Branch

Army 56.1%

Air Force 9.9%

Navy

Marines

14.2%

19.4%

Other 0.4%

Prior to the full survey, potential participants filled out a screener questionnaire

through Qualtrics. Within the screener questionnaire, there were three items that

indicated careless responding and two items necessary to be included in the study.

Participants needed to indicate that they were older than 18 years old and respond yes to

“I am/was in the military and have been deployed”. Additional questions included were

considered distractor questions and did not influence if the participant was eligible for the

study. If participants indicated they experienced at least one deployment, they were asked

two free response questions asking for the correct military acronyms. If they successfully

answered one of the two acronyms, participants were asked “Where and what year(s)

were you deployed?”. Participants were then asked to complete the Life-Events Checklist

13

(LEC-5; Weathers et al., 2013), PCL-5, and MIES questionnaires to determine if they

qualified for the study. The LEC ensured that participants experienced a traumatic event

that would qualify for a Criterion A event necessary for a PTSD diagnosis (American

Psychiatric Association, 2013). If their scores did not meet or exceed the cutoff scores

(28 for the MIES and 33 on the PCL-5), they were directed out of the study. If their

scores met either or both cutoffs, participants were asked to complete self-report

questionnaires assessing common maladaptive cognitions associated with a trauma.

Although moral injury and PTSD are latent variables, clinical elevations were required to

ensure the latent variables were present. The PCL-5 and MIES cutoff scores ensure that

participants were experiencing at least some levels of moral injury (Nash et al., 2013) and

are at the suggested cut-point for PTSD diagnosis (Blevins, Weathers, Davis, Witte, &

Domino, 2015; Weathers et al., 2013). Prior to accepting responses, qualitative data were

checked for nonsensical or inappropriate responses. Inappropriate responses were deleted

and not included in the dataset. Participant flow can be found in Figure 2.

Figure 2. Participant flow

14

Qualtrics was paid $7.50 per qualifying participant. Participants who did not qualify for

the study were entered into a raffle for a $25 Amazon gift card. All study procedures

were approved by the university’s Institutional Review Board, and informed consent was

obtained from all participants prior to data collection.

Measures

Eligibility

Life Events Checklist for DSM-5 (LEC-5; Weathers et al., 2013). The LEC-5 is a

17-item questionnaire used to gather information about traumatic experiences that would

qualify for a Criterion A event necessary for a PTSD diagnosis. The standard self-report

was utilized in this study. Participants were asked to indicate if they have ever

experienced, witnessed, or learned about a series of stressful life events (e.g., natural

disasters, serious accidents, assaults, combat exposure). In the current sample, 96.4% of

participants indicated that they had combat or exposure to a war zone (i.e., directly

experienced, witnessed, learned about, or was part of their job). Combat or exposure to a

war zone was also the LEC-5 event most frequently endorsed as “happened to me” by

participants. The LEC-5 has been used as a trauma exposure scale and has demonstrated

strong psychometric properties (Gray, Litz, Hsu, & Lombardo, 2004).

Moral Injury Events Scale (MIES; Nash et al., 2013; Bryan et al., 2013; Bryan et

al., 2015). The MIES is a 9-item self-report questionnaire that examines the degree to

which participants either committed, observed, learned about, or were victims of actions

that infringed upon their moral code. The MIES consists of three subscales; Other-

Transgressions (understanding of acts that others have committed that go against the

individual’s moral code), Self-Transgressions (acts perpetrated by the individual that

15

violate their moral code), and Betrayal (the individual believes they have been betrayed

by others. Individuals rate their agreement with statements on Likert scale ranging from 1

“Strongly Disagree” to 6 “Strongly Agree”. The MIES has demonstrated good internal

consistency in previous studies (Martin et al., 2017). Additionally, the measure has

demonstrated strong convergent and discriminant validity across military samples (Nash

et al., 2013; Bryan, et al., 2014; Bryan, et al., 2015).

Post-Traumatic Stress Disorder Symptom Checklist (PCL-5; Weathers et al.,

2013). The PCL-5 is an updated version of the symptom checklist that reflects the

changes in the diagnostic criteria. The PCL-5 is a 20-item questionnaire that examines the

extent to which individuals have been experiencing DSM-5 PTSD symptoms in the past

month. The individual is asked to refer to their most distressing event. Individuals rate

their symptoms with statements on Likert scale ranging from 0 “Not at all” to 4

“Extremely”. Scores are summed for a total severity score with 33 used as a total score

diagnostic cut off. There are four subscales corresponding to the four DSM-5 PTSD

clusters: intrusions (five items), avoidance (two items), negative alterations in cognitions

and mood (seven items), and alterations in arousal and activities (six items). Within this

study the PLC-5 was chosen instead of the military version of the PCL (PCL-M) because

the PCL-M is not updated to the new DSM-5 PTSD criteria. The PCL-5 has

demonstrated strong psychometrics with high internal consistency and construct validity

(Wortmann et al., 2016).

Observed Variables

Posttraumatic Maladaptive Beliefs Scale (PMBS; Vogt et al., 2012). The PMBS

is a 15-item self-report measure that examines the individual’s beliefs about current life

16

circumstances after exposure to trauma. The questionnaire has three subscales; threat of

harm, self-worth and judgment, and reliability and trustworthiness of others. Items will

be rated on a 7-point Likert scale ranging from 1“Not at all true for you” to 7

“Completely true for you”. Previous studies indicated that the PMBS has demonstrated

adequate internal consistency and reliability in military (Scher, Suvak, Resick, 2017;

Shipherd & Salters-Pedneault, 2017) and civilian samples (Vogt et al., 2012). Within this

sample, internal consistency was acceptable (threat of harm =.79; self-worth and

judgment =.76; reliability and trustworthiness of others =.80).

Heartland Forgiveness Scale (HFS; Thompson et al., 2005). The HFS is an 18-

item questionnaire that examines the how an individual typically responds to negative

events or feelings about the self, others, or situation. Responses will be scored on a 7-

point Likert scale ranging from 1 “Almost always false for me” to 7 “Almost always true

for me”. The HFS has demonstrated good internal consistency within military

populations (Bryan, Theriault & Bryan, 2014). Within this sample, internal consistency

for all subscales ranged from acceptable (self =.73; others =.76) to good (situation

=.80).

Deployment-Related Events Atonement Measure (DREAM). According to Nash

(2017), a “damaged concept of the world” is a component of moral injury. He suggested

that individuals with moral injury may “give or seek amends” to treat this aspect of moral

injury, which has been incorporated in the CBT for killing (Maguen et al., 2017). If there

is an untreated desire for atonement, it may lead to internal conflict. Currently, there is a

lack of psychometrically valid measurements of atonement. As such, a new atonement

scale has been created for this study. Participants will be asked to rate items on a 7-point

17

Likert scale ranging from “1 “Strongly Disagree” to 7 “Strongly Agree”. The 7-point

Likert scale was used to keep consistency throughout the study. The DREAM exhibited

very good internal consistency (=.88). The questions comprising the new scale can be

found in Table 2.

Table 2 Atonement Questionnaire

“I cannot be forgiven unless I give back”

“I think about the ways that I can make up for what I did”

“I feel like I need to make amends for what I did”

“I seek out ways to give back to feel better about my past”

“I feel like I need to make the world a better place because of what I did”

Note: Instructions were “Please think about how you’ve generally felt after returning

from deployment and thinking about your deployment related experiences”

Data Analytic Procedure

Prior to hypothesis testing, zero-order correlations were examined to determine

strength and directionality of the associations. Correlations (r) were interpreted utilizing

the Cohen (1988) cutoffs of 0.10 representing a small effect, 0.30 representing a medium

effect, and 0.50 a large effect. Correlations can be found in Table 3.

18

Table 3 Descriptive statistics and correlations for variables utilized in the primary

analyses

1 2 3 4 5 6 7

1. PBMS_TH -

2. PMBS_SWJ .571** -

3. PMBS_RTO .549** .553** -

4.

DREAM_Total

.077 .029 -.127* -

5. HFS_Self -

.460**

-

.672**

-

.486**

-.062 -

6. HFS_Others -

.442**

-

.493**

-

.529**

-.003 .438** -

7.

HFS_Situation

-

.502**

-

.602**

-

.529**

-.084 .662** .643** -

Mean 18.59 13.19 15.21 20.68 27.23 26.97 27.32

SD 6.90 5.91 6.15 8.30 7.00 7.27 7.51

Minimum 5.00 5.00 5.00 5.00 9.00 8.00 7.00

Maximum 35.00 29.00 33.00 35.00 42.00 42.00 42.00

Note: * = significant at the p < .05 level; ** = significant at the p < .01 level; PMBS_TH

= Posttraumatic Maladaptive Beliefs Scale – Threat of Harm; PMBS_SWJ =

Posttraumatic Maladaptive Beliefs Scale – Self Worth and Judgment; PMBS_RTO =

Posttraumatic Maladaptive Beliefs Scale – Reliability and Trustworthiness of Others;

HFS_Self = Heartland Forgiveness Scale – Self; HFS_Others = Heartland Forgiveness

Scales – Others; HFS_Situation = Heartland Forgiveness Scale – Situation.

Data were analyzed utilizing CFAs within SEM with 5,000 bootstrapping

resamples using MPlus Version 8.3. This statistical approach allows for examination of

observed and latent constructs. Additionally, this analytic approach allows for

examination of parsimonious fit, or consideration of both the fit of the model and the

number of estimated parameters. There were no missing data in the current sample.

Within this study, the observed variables were the maladaptive cognitions (i.e., PMBS

subscales, Heartland Forgiveness Scale subscales, and DREAM), meanwhile the latent

variables were moral injury and PTSD. The two latent variables were correlated during

19

analyses to ensure examination of two unique constructs. SEM can examine the shared

variance between distortions and the strength of the association with both latent variables.

Bryan and colleagues (2018) used a similar approach when examining the emotional

differences between moral injury and PTSD. Hypothesized associations can be found in

Figure 1.

Power Analysis

The estimation methods (e.g., maximum likelihood) and test of model fit (chi-

square) involved in SEM analyses suggested that a large sample size is required to

achieve appropriate power. In the literature, a minimum sample size of 200 is suggested

for any SEM analysis (Tomarken & Waller, 2005). For the current study, an online a

priori sample size calculator for SEM was used to calculate the number of participants

(Soper, 2019; Westland, 2010). For an SEM study with two latent variables (i.e., moral

injury and PTSD) and seven observed variables (i.e., PMBS subscales, Heartland

Forgiveness Scale subscales, and DREAM), a total of 223 participants were needed to

detect small to medium effects (δ=0.2) at .80 power with an alpha at .05. Due to the

possibility of missing data and validity errors, a total of 253 veterans were recruited.

Model Fit Indices

To test the hypotheses, the proposed model fit was examined through SEM fit

statistics. First, a chi-square goodness-of-fit statistic (2) test will be conducted to test

overall fit and the discrepancy between the sample and fitted covariance matrices. Next,

model fit will be examined through root mean square error of approximation (RMSEA;

Steiger, 1990). An RMSEA below .08 indicates an okay fit and values below .05 indicate

a good fit (Steigner, 1990). The standardized root mean square residual (SRMR)

20

examines the differences between the implied and observed covariance matrices. Similar

to RMSEA, the model will be determined to be a good fit if SRMR is less than .08 (Hu &

Bentler, 1999). Next, the comparative fit index (CFI) will be examined. CFI scores range

between 0 and 1. CFI scores above .90 indicate an adequate fit (Hu & Bentler, 1999).

Additionally, the Tucker-Lewis Index (TLI) will be examined. Similar to the CFI, the

TLI has a lower estimate of 0; however, TLI can exceed 1. The model is determined to be

a good fit for the data if the TLI is .90 or above (Hu & Bentler, 1999).

The relative model fit will be measured through Akaike Information Criteria

(AIC), Bayesian Information Criteria (BIC), and the Sample-Size Adjusted BIC

(SABIC). The AIC, BIC, and SABIC do not have interpretation or cut off values;

however, lower values indicate a better model fit (Kenny, 2012). These indices also assist

in comparing alternative models to determine the best fitting model (Kelloway, 2015).

Model Modification and Alternative Model

In addition to the proposed model (Figure 1), there will be modified and

alternative models tested to ensure appropriate fit. Model modification is utilized to either

improve parsimony or the overall fit of the model (MaCallum, 1986). For the current

study, model modification will consist of (1) deleting non-significant paths (loadings less

than .35), utilizing the “theory trimming” approach (Pedhauzer, 1982) and (2)

theoretically driven associations (Kelloway, 2015). Modified models will be tested using

the same model fit procedures. The modified model will be deemed a better fit than the

proposed model if the results of the chi-square test of the modified model decreases by

more than the critical value (calculated by the changes in the degrees of freedom) and the

model fit indices described above. Although all fit indices will be examined to compare

21

models, it will be especially important to take into account the AIC, BIC, and SABIC, as

they penalize models based on complexity (Kenny, 2012; Kelloway, 2015).

When conducting SEM analyses that may have more than one a priori model, it is

suggested to test the hypothesized analysis to an alternative model (Jöreskog, 1993). For

the current study, the alternative model tested was all maladaptive cognitions associated

with a unitary “trauma” latent variable. After the most parsimonious modified model has

been identified, that model will be tested against the alternative model. Testing the

“trauma” latent variable negates the confirmation bias that occurs when researchers only

examine their hypothesized model (Kline, 2011; Shah & Goldstein, 2006). Furthermore,

testing a unitary “trauma” latent variable will examine if a simpler model is a better fit for

the data rather than a more complex model with two latent variables (i.e., moral injury

and PTSD).

22

CHAPTER III - RESULTS

A series of five CFAs were conducted to examine which maladaptive cognitions

were associated with moral injury and PTSD. The original proposed model was tested

and modified until the most parsimonious model was identified. A comparison of all

modified models can be found in Table 4.

23

Table 4 Goodness-of-Fit Indices for the proposed models

Model df χ2 RMSEA SRMR CFI TLI AIC BIC SSAB

Model 1 13 48.771 .104 .039 .945 .910 9578.833 9656.568 9586.824

Model 2 13 48.947 .105 .039 .944 .910 9579.010 9656.744 9587.000

Model 3 7 21.899 .092 .030 .977 .950 8787.903 8858.571 8795.168

Model 4 3 4.690* .047 .015 .997 .987 8778.694 8863.496 8787.411

Model 5 5 5.637* .022 .016 .999 .997 8775.641 8853.376 8783.632

Alternative Model 11 14.068* .037 .028 .994 .989 9548.869 9633670 9557.586

Note: * = p > .05

24

Original Model

The first CFA model tested was the original hypothesized model (Figure 1).

Examination of the standardized correlation between latent variables indicate that the

correlation between moral injury and PTSD exceeds 1 (1.033). As such, the model is

inadmissible. Although this model cannot be accepted, model statistics will be reported to

examine comparative models and examine how to modify the model.

The Chi-Square Test of Model fit (χ2(13, N = 253) = 48.771, p < .001) was

significant, indicating that the hypothesized model may not be the best fit. The RMSEA

was .104 (90% CI = .074 - .136), signifying an unacceptable fit; however, the SRMR

(.039) suggested a good fit. Similarly, the CFI (0.945) and TLI (0.910) both suggested a

good fit. The AIC (9578.833), BIC (9656.568) and SSAB (9586.824) were used as

baseline scores to compare with alternative models.

The factor loadings were the examined to determine how the model could

improve. A diagram of the original model with standardized estimates and significant

pathways can be found in Figure 3.

25

Figure 3. Original model with significant pathways and standardized estimates (STDYX)

The HFS – Self was not significantly associated with the latent construct of moral

injury (p =.103). All other hypothesized associations were significant (ps <.001). Given

the fit statistics and the non-significant pathway, additional models were tested. Model

results can be found in Table 5.

26

Table 5 Table of standardized model results for original proposed model

Estimate S.E. EST./S.E. p

Moral Injury by

Dream 0.706 0.038 18.549 <.001

PMBS_SWJ 0.658 0.041 16.168 <.001

RMBS_RTO 0.862 0.025 34.550 <.001

HFS_O -0.730 0.035 -21.101 <.001

HFS_SE 0.108 0.066 1.632 .103

PTSD by

PMBS_TH 0.687 0.047 14.701 <.001

HFS_SIT -0.603 0.049 -12.213 <.001

PTSD with

Moral Injury 1.033 0.050 20.649 <.001

Note: DREAM = Deployment-Related Events Atonement Measure; PMBS_SWJ =

Posttraumatic maladaptive beliefs scale, self-worth and judgment subscale; PMBS_RTO

= Posttraumatic maladaptive beliefs scale, reliability and trustworthiness of others

subscale; HFS_O = Heartland Forgiveness Scale, others subscale; PMBS_TH =

posttraumatic maladaptive beliefs scale, threat of harm subscale; HFS_SIT = Heartland

Forgiveness Scale, situation subscale; HFS_SE = Heartland Forgiveness Scale, self

forgiveness

Model #2

A second CFA model was tested utilizing both “theory trimming” (Pedhauzer,

1982) and theoretically driven (Kelloway, 2015) changes. The second model examined if

the HFS – Self was associated with the latent construct of PTSD instead of moral injury.

Similar to model 1, the standardized correlation between latent variables indicate that the

correlation between moral injury and PTSD exceeds 1 (1.025). As such, the model is

inadmissible. Although this model cannot be accepted, model statistics will be reported to

examine comparative models and examine how to modify the model.

The Chi-Square Test of Model fit (χ2(13, N = 253) = 48.947, p < .001) was

significant, indicating that the modified model may not be the best fit. The RMSEA was

.105 (90% CI = .074 - .137), demonstrating an unacceptable fit; however, the SRMR was

27

.039, suggested a good fit. Similarly, the CFI (0.944) and TLI (0.910) both suggested a

good fit. The AIC (9579.010), BIC (9656.744) and SSAB (9587.000) scores increased

compared to the original model. Overall, the second model did not indicate a significantly

better fit than the original model. Full model results can be found in Table 6.

Table 6 Table of standardized model results for model 2


Moral Injury by

Dream 0.705 0.038 18.499 <.001

PMBS_SWJ 0.658 0.041 16.179 <.001

RMBS_RTO 0.863 0.025 35.543 <.001

HFS_O -0.731 0.035 -21.117 <.001

PTSD by

PMBS_TH 0.691 0.046 15.138 <.001

HFS_SIT -0.606 0.049 -12.394 <.001

HFS_SE 0.103 0.066 1.568 .117

PTSD with

Moral Injury 1.025 0.048 21.203 <.001







forgiveness

Model #3

A third CFA model was tested utilizing “theory trimming” (Pedhauzer, 1982) and

data-driven approaches. The third model excluded the HFS – Self and correlated

DREAM with PMBS – Reliability and Trustworthiness of Others (PMBS-RTO). The

second model’s model modification indices indicated that adding the correlation would

assist in producing a superior model fit (M.I. = 17.189). Furthermore, the correlation

28

table indicated a significant association between the DREAM and PMBS–RTO variables

(Table 3).

The Chi-Square Test of Model fit (χ2(7, N = 253) = 21.899, p = .003) was

significant, indicating that the modified model may not be the best fit. The RMSEA was

.092 (90% CI = .050 - .136), indicating a mediocre fit. Although the RMSEA was below

the cutoff of .10, the upper band of the confidence interval exceeds the cutoff of poor fit.

The SRMR was .030, indicating a good fit. Similarly, the CFI (0.977) and TLI (0.950)

both indicated a good fit. The AIC (8787.903), BIC (8858.571) and SSAB (8795.168)

scores decreased compared to the original model. Although the fit indices suggested that

the current model could be improved, there was a significant (p < .01) decrease in the χ2

critical value given the decrease in the degrees of freedom. The significant decrease in χ2

and decreases in AIC, BIC, and SSAB indicate that the third model is a significantly

better fit than the original model. Full model results can be found in Table 7.

29



Moral Injury by

Dream 0.784 0.036 21.768 <.001

PMBS_SWJ 0.646 0.039 16.482 <.001

PMBS_RTO 0.917 0.025 37.389 <.001

HFS_O -0.697 0.036 -19.207 <.001

PTSD by

PMBS_TH 0.698 0.046 15.245 <.001

HFS_SIT -0.593 0.049 -12.051 <.001

PTSD with

Moral Injury 0.992 0.049 20.171 <.001

DREAM with

PMBS_RTO -0.674 0.213 -3.161 .002






Forgiveness Scale, situation subscale

Model #4

A fourth CFA model was tested utilizing theoretical changes. Correlations

between subscales of the same measure were added to ensure examination of the unique

qualities of each construct. The subscales within the same measures were significantly

correlated with each other (Table 3). Furthermore, for model four, DREAM was

correlated with HFS – Others given the modification indices of model 3 (M.I. = 8.066).

The Chi-Square Test of Model fit (χ2(3, N = 253) = 4.690, p = .196) was non-

significant, indicating a good model fit. The RMSEA (.047, 90% CI = <.001 - .125) and

SRMR (.015) suggest a good fit. The CFI and TLI both demonstrated a good fit (0.997

and 0.987, respectively). The AIC (8778.694), BIC (8863.496) and SSAB (8787.411)

30

scores decreased compared to model 3. Furthermore, as compared to model 3, there was a

significant (p < .01) decrease in the χ2 critical value corresponding with the change in the

degrees of freedom. The significant decrease in χ2 and decreases in AIC, BIC, and SSAB

indicate that the model 4 is a significantly better fit than model 3. Although model 4

demonstrated the better fit, there were two non-significant associations (PMBS_SWJ

with PMBS_TH, p = .349; HFS_O with HFS_SIT, p = .783). Full model results can be

found in Table 8.



Moral Injury by

Dream 0.847 0.042 20.136 <.001

PMBS_SWJ 0.646 0.041 15.885 <.001

RMBS_RTO 0.872 0.033 26.692 <.001

HFS_O -0.760 0.038 -20.246 <.001

PTSD by

PMBS_TH 0.668 0.048 14.022 <.001

HFS_SIT -0.640 0.051 -12.447 <.001

PTSD with

Moral Injury 0.992 0.050 18.655 <.001

DREAM with

PMBS_RTO -0.695 0.274 -2.534 .011

HFS_O 0.431 0.186 2.320 .020

PMBS_SWJ with

PMBS_TH -0.067 0.071 -0.937 .349

PMBS_RTO with

PMBS_TH 0.297 0.105 2.834 .005

HFS_O with

HFS_SIT -0.025 0.089 -0.275 .783







31

Model #5

A fifth CFA model was tested with the non-significant associations removed. The

Chi-Square Test of Model fit (χ2(5, N = 253) = 5.637, p = .343) was non-significant,

indicating a good model fit. The RMSEA (.022, 90% CI = <.001 - .093) and SRMR

(.016) suggest a good fit. The CFI and TLI both demonstrated a good fit (0.999 and

0.997, respectively). The fifth model demonstrated the lowest AIC (8775.641), BIC

(8853.376) and SSAB (8783.632) scores of all potential models. Furthermore, the

decrease in χ2 in model 4 corresponding to the degrees of freedom did not exceed the

critical value necessary to suggest a better fit than model 5. The χ2 value and decreases in

AIC, BIC, and SSAB indicated that the model 5 is a significantly better fit than model 4.

There were no additional modification indices that would suggest statistically important

changes to the model. As such, model 5 is the most parsimonious fit for the data. Full

model statistics can be found in Table 9 and diagram of model 5 with significant

pathways can be found in Figure 4.

32



Moral Injury by

Dream 0.861 0.040 21.472 <.001

PMBS_SWJ 0.642 0.040 15.925 <.001

RMBS_RTO 0.879 0.029 29.974 <.001

HFS_O -0.756 0.035 -21.304 <.001

PTSD by

PMBS_TH 0.665 0.047 14.111 <.001

HFS_SIT -0.637 0.050 -12.637 <.001

PTSD with

Moral Injury 0.924 0.048 19.139 <.001

DREAM with

PMBS_RTO -0.826 0.289 -2.858 .004

HFS_O 0.481 0.187 2.569 .010

PMBS_RTO with

PMBS_TH 0.318 0.096 3.319 .001







33

Figure 4. Model 5 with significant pathways and standardized estimates (STDYX)







Alternative Model

Finally, an alternative model was tested to determine if the data instead support

moral injury and PTSD as one “trauma” construct. An alternative model with a unitary

“trauma” construct comprising all maladaptive cognitions was tested against the best

fitting modified model (model #5). The covariates included in model 5 were also

included in the alternative model. The Chi-Square Test of Model fit (χ2(11, N = 253) =

34

14.806, p = .192) was non-significant, indicating a good model fit. Similarly, the RMSEA

(.037, 90% CI = <.001 - .081) and SRMR (.028) suggest a good fit. The CFI and TLI

both demonstrated a good fit (0.994 and 0.989, respectively). As compared to the fifth

model, the alternative model had higher AIC (9548.869), BIC (9633.670) and SSAB

(9557.586) scores. The change in the χ2 value indicates that alternative model may be a

better fit for the data than model 5. The RMSEA and SRMR indicated good fit; however,

were higher than that of model 5. Furthermore, the AIC BIC and SSAB were all higher

than model 5. The AIC, BIC, and SSAB are parsimonious fit indices utilized to compare

models with varying parameters and complexity. Given the higher AIC, BIC, and SSAB,

the alternative model is not a more parsimonious fit for the data. Full model statistics can

be found in Table 10 and a diagram of the alternative model with significant pathways

can be found in Figure 5.

35

Table 10 Table of standardized model results for alternative model


Trauma by

Dream 0.843 0.038 22.481 <.001

PMBS_SWJ 0.650 0.039 16.471 <.001

RMBS_RTO 0.874 0.029 29.878 <.001

HFS_O -0.754 0.035 -21.461 <.001

PMBS_TH 0.629 0.044 14.349 <.001

HFS_SIT -0.593 0.044 -13.369 <.001

HFS_SE 0.093 0.054 1.463 .143

DREAM with

PMBS_RTO -0.684 0.223 -3.063 .002

HFS_O 0.395 0.152 2.590 .010

PMBS_RTO with

PMBS_TH 0.261 0.090 2.905 .004







subscale

36

Figure 5. Alternative model with significant pathways and standardized estimates

(STDYX)







subscale

37

CHAPTER IV – DISCUSSION

Previous research has focused on separating moral injury and PTSD through

emotions and physiological responses (Bryan et al., 2018), leaving a gap in the literature

in relation to the role of cognitions. Cognitions have been identified as crucial to the

development of morality (Gibbs, 2003; Hoffman, 2001; Kohlberg, 1984) and can be

distorted after a traumatic event (Brewin, 2007; Ehlers & Clark, 2000). Furthermore, it

has been posited that moral injury and PTSD are two distinct constructs (Jinkerson, 2016)

that require separate psychological treatment (Steenkamp et al., 2016). The purpose of

the current study was to build upon the current literature by examining how maladaptive

cognitions are associated with either moral injury or PTSD.

The results of the current investigation highlighted how moral injury and PTSD

are associated with distinct maladaptive cognitions. The best-fitting modified model was

compared to an alternative model in which moral injury and PTSD were collapsed into

one unitary “trauma” variable. Although the chi-square test of fit indicated the alternative

model was a better fit for the data, the parsimonious fit statistics gave support to model 5.

Results of the alternative model supported previous research indicating that maladaptive

cognitions as core components of trauma symptomatology (APA, 2013; Brewin, 2007;

Ehlers & Clark, 2000) and that maladaptive cognitions previously associated with trauma

are, indeed, associated with trauma. The alternative model was more simplistic than

model 5 and did not allow for examination of if maladaptive cognitions were associated

with moral injury or PTSD. Theoretically, there is substantial research to support moral

injury as a variable separate from PTSD (see Griffin et al., 2019 for a review).

Additionally, when constructing SEM models, theory should assist in developing

38

appropriate models (Kline, 2011; Pedhauzer, 1982). Therefore, given the theoretical

background and parsimonious fit statistics, the more complex model 5 may be the best

and most useful interpretation of the data. The modified model provides insight into

moral injury and PTSD. As such, the results of model 5 will be discussed further.

The first hypothesis was that moral injury will have five distinct maladaptive

cognition factor loadings (i.e., self-worth and judgment, reliability and trustworthiness of

others, forgiveness of others, forgiveness of self, and atonement). The second hypothesis

was that PTSD will have two factor loadings (i.e., threat of harm and forgiveness of the

situation). The hypotheses (Figure 1) were partially supported with the proposed model

requiring slight modifications (Figure 4). Namely, self-forgiveness was the only subscale

of the proposed model that was non-significantly associated with the hypothesized

construct.

Contrary to the hypotheses, self-forgiveness was not associated with moral injury

nor was it associated with PTSD. Conceptually, self-forgiveness has been identified as a

major component of treatment of moral injury (Purcell, Griffin, Burkman, Maguen,

2018). In fact, the focus on self-forgiveness has been identified as a unique factor that

separates moral injury treatment from PTSD (Burkman, Purcell, & Maguen, 2019). The

results of the current investigation indicate that self-forgiveness may play a role in the

treatment of a facet of moral injury (i.e. self-transgressions); however, may not be crucial

when examining overall moral injury.

Despite the non-significant results for self-forgiveness, there was a significant

negative association between forgiveness of others and moral injury. Forgiveness of

others may play an important role in overall moral injury given the other facets of moral

39

injury (i.e. betrayal and others’ transgressions) focusing primarily on the actions

committed by others. Furthermore, forgiveness of others may also be associated with

moral injury within military personnel when individuals blame others for their

transactions (i.e., unit commands from leader or government officials). Qualitative

responses from previous literature highlighted how within military personnel, power and

rank dynamics affect individuals’ abilities to act morally (Held et al., 2018). Held and

colleagues (2018) noted that one participant who experienced moral injury stated, “You

are a lower enlisted soldier so you have to do as you are told instead of arguing” (p. 5).

Furthermore, another participant noted that, “[I knew that not helping was wrong] the

moment I got the order” (Held et al., 2018, p. 4). Similarly, qualitative responses from the

current investigation indicated that some participants felt as though leaders forced them

to act against their morals (i.e., “orders given which countered the stated mission”).

Overall, results indicate that forgiveness of others may help military personnel with

moral injury across all domains.

There is evidence to suggest that higher levels of forgiveness are associated with

lower PTSD symptoms, yet this association fluctuates depending on the samples’

demographics (Cerci & Colucci, 2017). Empirical examination of forgiveness is difficult

due to the variety of measurements available (Cerci & Colucci, 2017). Furthermore, as it

pertains to traumatic experiences, the lay concept of forgiveness may be different than the

research conceptualization (i.e., forgetting, excusing, reconciling, condoning; Kearns &

Fincham, 2004). In the current sample, as hypothesized, forgiveness of the situation was

negatively associated with PTSD. Given the complex association between general

forgiveness and PTSD, it is important to understand forgiveness as a heterogenous

40

variable. Forgiveness of the situation may play an important role for treatment of PTSD

rather than moral injury because of externalized experiences. Namely, the etiology of

moral injury is internalized while PTSD may be more external (MacNair, 2002; Marx et

al., 2010). Forgiveness of the situation may aid in decreasing fear, which can assist in the

habituation process used in PTSD treatments to decrease symptoms (Gray et al., 2012;

Litz et al., 2016; Steenkamp et al., 2013). Understanding the different aspects of

forgiveness that comprise moral injury and PTSD can assist in developing and

understanding treatments for these disorders.

Consistent with the hypothesis, the posttraumatic maladaptive belief subscales of

self-worth and judgment and reliability and trustworthiness of others were associated

with moral injury. This is the first study to examine how the PMBS is associated with

moral injury. The PMBS was originally created to be “useful for the assessment of

survivors of a variety of different types of traumatic events” (Vogt et al., 2012, p. 309).

Since the PMBS is not limited to specific traumatic events, it can be used as a tool to

understand the maladaptive cognitions associated with moral injury. The results of the

current investigation are consistent with the previous literature of moral injury focusing

on the self and interpersonal relationships. Specifically, self-worth and judgment may be

similar to the self-forgiveness hypothesized in moral injury treatments (Burkman, Purcell,

& Maguen, 2019; Purcell, Griffin, Burkman, Maguen, 2018). In the current study, the

self-worth and judgment scale was significantly correlated with self-forgiveness in which

higher maladaptive cognitions of self-worth and judgment were associated with lower

self-forgiveness (see Table 3). Finally, threat of harm was associated with PTSD. These

results are in accord with previous literature suggesting that PTSD is marked by

41

physiological concerns, stems from mortal danger, and includes hyperarousal of threat

response (Battles et al., 2018; Bryan et al., 2018; Litz et al., 2016). Future research should

consider examining maladaptive cognitions associated with moral injury through clinical

interviews in conjunction with the PMBS subscales.

The final maladaptive cognition tested was the association between deployment

related events atonement and moral injury. It has been hypothesized that atonement is a

core concept of moral injury in which individuals may seek to make amends for morally

injurious events (Nash, 2017). Indeed, the results of the current investigation suggest

atonement as a concept associated with moral injury in which individuals who experience

these events may desire to make reparations for these events. Understanding atonement

may assist in clinicians addressing this as a maladaptive cognition in treatment of moral

injury.

The exploratory hypothesis was supported with the DREAM demonstrating

appropriate preliminary psychometrics with good internal consistency. The DREAM was

created for the current study to empirically investigate how atonement can be a

maladaptive cognition associated with moral injury. Previous researchers have

hypothesized that individuals with moral injury may seek amends for their actions (Nash,

2017). Give the infancy of the measure, the exploratory hypothesis was to examine the

internal consistency of the DREAM. The DREAM exhibited very good internal

consistency within the current sample; however, future research into the psychometrics is

necessary for continued use.

42

Implications

Theoretical

The current investigation provides preliminary empirical support for some of the

theorized associations between moral injury and maladaptive cognitions. There was

support for atonement, self-worth and judgment, reliability and trustworthiness of others,

and forgiveness of others. Despite theoretical support, there was no empirical support to

suggest that forgiveness of self is associated with overall moral injury. The results of the

current investigation suggest that maladaptive cognitions may be another factor that

separates moral injury from PTSD, building on to the physiological and emotional

differences described by Bryan and colleagues (2018). Furthermore, given the current

results, it may be beneficial to add a criterion of at least one of these distinct maladaptive

cognitions to the proposed moral injury syndrome (Jinkerson, 2016).

Clinical

Currently, there are no independent treatments for moral injury meeting the

criteria (Tolin et al., 2015) for empirically supported treatments. Although

transdiagnostic and adjunct treatments (i.e., TrIGER, AD, and killing in combat) have

demonstrated decreases in the core concepts of moral injury (i.e., guilt and shame), these

treatments fail to address the maladaptive cognitions associated with moral injury. The

results of the current investigation may assist in the modification of some of these

treatments to address maladaptive cognitions. Treatment modules focusing on

identifying, acknowledging, and evaluating maladaptive cognitions may be helpful.

Specifically, modifications of CPT (an EBT for PTSD which focuses on cognitions)

examining these maladaptive cognitions may be helpful (Resick et al., 2008). These

43

results may also give clinicians information about what maladaptive cognitions to focus

on during treatment, allowing the patient to receive efficient care directly related to their

moral injury. Efficient care may create less burden on clients, increasing the ability to

successfully implement clinical trials for moral injury treatments to be considered

efficacious (Alexander, 2013).

Limitations

The current study’s results should be interpreted alongside its limitations.

Primarily, the study was cross-sectional in nature, limiting the ability to draw causal and

temporal relationships. Next, the participants were primarily white (78.7%) and male

(77.1%), which may limit generalizability; however, the military tends to be composed of

this demographic makeup. Furthermore, although participants endorsed multiple branches

of the military, the majority of the participants were associated with the Army (56.1%).

This limits generalizability to other branches of the military. Future research should

examine maladaptive cognitions associated with trauma in a variety of military branches.

The current study utilized self-report measures, which may be vulnerable to response

bias. Although participants were required to meet the clinical cutoffs for moral injury

and/or PTSD, participants may have response biases concerning maladaptive cognitions.

This limitation is especially notable given that military personnel may be motivated to

obscure emotional distress (Hoge & Castro, 2012; Blocker & Miller, 2013). Similarly, the

use of the DREAM is a limitation given its lack of validity (i.e., content, construct, and

criterion-related) and reliability (i.e., test-retest). Given the lack of empirical measures to

examine deployment related atonement, a new measure was created for this study. Future

research should further examine the psychometrics of this measure across military

44

branches. Finally, the current sample utilized online recruitment. Although there were

stringent selection criteria that utilized techniques suggested to recruit military veterans

(i.e., free response acronym questions and screener questions), military status of

participants could not be confirmed (Morgan, 2016, p. 10).

Strengths

The current study also had a number of strengths. Primarily, the stringent

selection criteria ensured military personnel who experienced traumatic experiences. This

online community sample had elevations in moral injury and/or PTSD as a requirement

to participate in the study as well as 41.1% of participants endorsing lifetime suicidal

ideation and 15.4% endorsing a past suicide attempt. Additionally, although a foreign

deployment was not necessary to qualify for the study, an overwhelming majority of the

sample endorsed this experience (90.1%).

Future Research

Future research should seek to build upon the results of the current investigation.

Namely, the combination of self-report measures and clinical interviews may ensure

presence of moral injury. Analysis of qualitative interviews may also provide insight into

the maladaptive cognitions associated with moral injury. Additionally, future research

may also examine the sub-scales of the moral injury events scale (i.e., self-transgressions,

others’ transgressions, and betrayal) to further evaluate how maladaptive cognitions

affect each aspect of moral injury. Finally, clinical research may also examine how the

maladaptive cognitions associated with moral injury change throughout treatment. Since

cognitive change may be a mechanism within the treatment of PTSD (Scher et al., 2017),

cognitive change may also be a mechanism for moral injury.

45

Conclusions

The current study was the first of its kind, to my knowledge, to examine the

maladaptive cognitions associated with moral injury and PTSD. Previously, the study of

maladaptive cognitions has been limited to their association with PTSD. The most

parsimonious model contained six out of the seven hypothesized associations. The

current investigation provides further empirical support to identify moral injury as a

construct distinct from PTSD. Finally, the results of the current study can assist in

treatment of moral injury and PTSD. Clinicians who treat moral injury may benefit from

acknowledging and challenging the maladaptive cognitions specific to moral injury (i.e.,

atonement, self-worth and judgment, reliability and trustworthiness of others, and

forgiveness of others) to assist their clients in healing.

46

APPENDIX A - IRB Approval Letter

47

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