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The University of Southern Mississippi The University of Southern Mississippi
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Dissertations
Summer 2020
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
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COPYRIGHT BY
Rachel Lynn Martin
2020
Published by the Graduate School
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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
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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."
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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.
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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
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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
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Theoretical ............................................................................................................ 42
Clinical .................................................................................................................. 42
Limitations ................................................................................................................ 43
Strengths ................................................................................................................... 44
Future Research ........................................................................................................ 44
Conclusions ............................................................................................................... 45
APPENDIX A ................................................................................................................... 46
REFERENCES ................................................................................................................. 47
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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 7 Table of standardized model results for model 3 ................................................. 29
Table 8 Table of standardized model results for model 4 ................................................. 30
Table 9 Table of standardized model results for model 5 ................................................. 32
Table 10 Table of standardized model results for alternative model ................................ 35
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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
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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
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SRMR Standardized Root Mean Square Residual
TLI Ticker-Lewis Index
TrIGER Trauma Informed Guilt Reduction Therapy
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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.
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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;
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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,
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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).
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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
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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,
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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
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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
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(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
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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.
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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%
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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
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(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
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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
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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
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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
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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.
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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
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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)
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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
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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).
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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.
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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
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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.
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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.
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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
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.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
Estimate S.E. EST./S.E. p
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
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 #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
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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.
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Table 7 Table of standardized model results for model 3
Estimate S.E. EST./S.E. p
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
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
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)
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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.
Table 8 Table of standardized model results for model 4
Estimate S.E. EST./S.E. p
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
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
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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.
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Table 9 Table of standardized model results for model 5
Estimate S.E. EST./S.E. p
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
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
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Figure 4. Model 5 with significant pathways and standardized estimates (STDYX)
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
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) =
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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.
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Table 10 Table of standardized model results for alternative model
Estimate S.E. EST./S.E. p
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
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
subscale
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Figure 5. Alternative model with significant pathways and standardized estimates
(STDYX)
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
subscale
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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
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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
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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
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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
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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.
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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
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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
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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.
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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.
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APPENDIX A - IRB Approval Letter
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