Moral injury process and its psychological consequences among Israeli combat veterans

Zerach, Gadi; Levi‐Belz, Yossi

doi:10.1002/jclp.22598

Cited by 64 publications

(49 citation statements)

References 54 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…We used the effect size for the overall scale if effect sizes for multiple subscales were reported (Harman & Lee, ). Averages were calculated for studies that reported more than one shame outcome (Dorahy et al., ) or on multiple shame subscales without a total score (Neufeld, Sikkema, Lee, Kochman, & Hansen, ; Straub, McConnell, & Messman‐Moore, ; Zerach & Levi‐Belz, ). Borenstein, Hedges, Higgins, and Rothstein () suggest the weighting of average effect sizes; however, recent work has shown that this may create potential bias by introducing a third, confounding variable in a random‐effects meta‐analysis (Shuster, ).…”

Section: Methodsmentioning

confidence: 99%

Association Between Shame and Posttraumatic Stress Disorder: A Meta‐Analysis

López‐Castro

Saraiya

Zumberg‐Smith

et al. 2019

Journal of Traumatic Stress

View full text Add to dashboard Cite

Posttraumatic stress disorder (PTSD) is a complex condition with affective components that extend beyond fear and anxiety. The emotion of shame has long been considered critical in the relation between trauma exposure and PTSD symptoms. Yet, to date, no meta‐analytic synthesis of the empirical association between shame and PTSD has been conducted. To address this gap, the current study summarized the magnitude of the association between shame and PTSD symptoms after trauma exposure. A systematic literature search yielded 624 publications, which were screened for inclusion criteria (individuals exposed to a Criterion A trauma, and PTSD and shame assessed using validated measures of each construct). In total, 25 studies employing 3,663 participants met full eligibility criteria. A random‐effects meta‐analysis revealed a significant moderate association between shame and posttraumatic stress symptoms, r = .49, 95% CI [0.43, 0.55], p < .001. Moderator analyses were not completed due to the absence of between‐study heterogeneity. Publication bias analyses revealed minimal bias, determined by small attenuation after the superimposition of weight functions. The results underscore that across a diverse set of populations, shame is characteristic for many individuals with PTSD and that it warrants a central role in understanding the affective structure of PTSD. Highlighting shame as an important clinical target may help improve the efficacy of established treatments. Future research examining shame's interaction with other negative emotions and PTSD symptomology is recommended.

show abstract

Section: Methodsmentioning

confidence: 99%

Association Between Shame and Posttraumatic Stress Disorder: A Meta‐Analysis

López‐Castro

Saraiya

Zumberg‐Smith

et al. 2019

Journal of Traumatic Stress

View full text Add to dashboard Cite

show abstract

“…In support of this hypothesis, a previous study of combat-deployed Marines found a significant direct association between betrayal and anger and an indirect association with PTSD via anger ( 25 ). Similarly, in a recent study of Israeli combat veterans, betrayal-based morally injurious events were associated with symptoms of posttraumatic stress, depressive attributions, and self-disgust ( 45 ). Thus, these results suggest that additional “mechanisms” of moral injury such as anger, rage, and disgust should be examined in future studies and potentially targeted in treatment.…”

Section: Discussionmentioning

confidence: 93%

“…Secondary data analysis limited the range of tested moral injury mechanisms. For example, the parent study did not include measures of anger or disgust, which may be additional intervening variables between betrayal and PTSD-depression ( 25 , 45 ). We had relatively lower endorsement of MST compared to combat, and thus future studies may benefit from oversampling for veterans who have experienced MST.…”

Section: Discussionmentioning

confidence: 99%

Mechanisms of Moral Injury Following Military Sexual Trauma and Combat in Post-9/11 U.S. War Veterans

et al. 2018

View full text Add to dashboard Cite

Objective: Moral injury may result from perpetration-based and betrayal-based acts that violate deeply held norms; however, researchers and clinicians have little guidance about the moral injury syndrome's specific developmental pathways following morally injurious events. The present study's objective was to examine the direct and indirect pathways proposed in a frequently cited model of moral injury (1) in relation to two types of military-related traumas [experiencing military sexual trauma (MST) and combat exposure].Methods: Secondary analyses were conducted within a sample of post-9/11 veterans at a Southwestern Veterans Health Care System (N = 310) across two time-points. Structural equation modeling tested the direct and indirect pathways from MST and combat to a PTSD-depression factor via betrayal, perpetration, guilt, and shame.Results: Betrayal accounted for the association between MST and PTSD-depression (β = 0.10, p < 0.01, 95% CI = 0.01 − 0.11) and perpetration accounted for the association between combat and PTSD-depression (β = 0.07, p < 0.05, 95% CI = 0.02 − 0.14). The indirect path from combat to shame to PTSD-depression was significant (β = 0.16, p < 0.01, 95% CI = 0.07 − 0.28) but the path through guilt was not. The specific indirect paths through perpetration or betrayal to shame or guilt were non-significant.Conclusions: Betrayal and perpetration are associated with PTSD-depression following MST and combat. Results suggest multiple pathways of moral injury development following different military traumas and morally injurious events. Implications for moral injury conceptualization and treatment are discussed.

show abstract

“…Moral injury, conceptualized by Litz et al (2009), is the impact on the subject of various acts of omission or commission in military that produce inner conflict. Litz's widely cited model of moral injury claims that transgressive acts may lead to guilt, shame, loss of trust, spiritual/existential issues, social problems, depression, anxiety, re‐experiencing the moral conflict, intrusive thoughts, numbing and demoralization (Litz et al, 2009; Zerach & Levi‐Belz, 2018).…”

Section: Moral Injurymentioning

confidence: 99%