The relationship between moral injury appraisals, trauma exposure, and mental health in refugees

Hoffman, Joel; Liddell, Belinda J.; Bryant, Richard A.; Nickerson, Angela

doi:10.1002/da.22787

Cited by 56 publications

(121 citation statements)

References 66 publications

(120 reference statements)

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“…Hoffman et al (2018) found support for two ways that traumatic events could be appraised as moral violations in a diverse refugee population: transgression by others (MI-Other) and transgressions by oneself (MI-Self). In both populations, PTSD symptoms were associated with MI-Other but not MI-Self appraisals (Bryan et al, 2015;Hoffman et al, 2018), indicating that perceived moral violations enacted by the self are less likely to be associated with PTSD. In contrast, results have been less consistent across military samples for symptoms such as anger, depression and suicidal ideation (Bryan et al, 2015;Bryan, Bryan, Morrow, Etienne, & Ray-Sannerud, 2014).…”

Section: Introductionmentioning

confidence: 90%

“…Appraisals that events have violated important moral beliefs have been found to be associated with greater depression, PTSD, anger, guilt and shame in a military sample, above and beyond trauma exposure (Lancaster & Erbes, 2017). Similarly, moral injury appraisals have been found associated with PTSD, anger and depression above and beyond trauma exposure in a refugee sample (Hoffman, Liddell, Bryant, & Nickerson, 2018). Therefore, understanding how the mechanism by which moral injury links these outcomes to traumatic experiences is crucial for designing effective interventions.…”

Section: Introductionmentioning

confidence: 99%

“…Studies in military populations have identified three ways that traumatic events may be appraised as moral violations: transgressions by oneself, transgressions by others and betrayal by others (Bryan et al, 2015;Nash et al, 2013). Hoffman et al (2018) found support for two ways that traumatic events could be appraised as moral violations in a diverse refugee population: transgression by others (MI-Other) and transgressions by oneself (MI-Self). In both populations, PTSD symptoms were associated with MI-Other but not MI-Self appraisals (Bryan et al, 2015;Hoffman et al, 2018), indicating that perceived moral violations enacted by the self are less likely to be associated with PTSD.…”

Section: Introductionmentioning

confidence: 99%

“…In contrast, results have been less consistent across military samples for symptoms such as anger, depression and suicidal ideation (Bryan et al, 2015;Bryan, Bryan, Morrow, Etienne, & Ray-Sannerud, 2014). However, both MI-Other and MI-Self appraisals have been found associated with increased anger and depression symptoms in refugee samples (Hoffman et al, 2018;Nickerson et al, 2015). Accordingly, there is emerging evidence that moral injury represents a salient construct for conceptualizing the psychological impact of refugee trauma.…”

Section: Introductionmentioning

confidence: 99%

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A latent profile analysis of moral injury appraisals in refugees

Hoffman

Liddell

Bryant

et al. 2019

European Journal of Psychotraumatology

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Background: Refugees often exhibit reactions to traumatic events that may be conceptualized as moral injury (i.e. the impact of events that violate important moral values). There have been two types of moral injury appraisals found in refugees: transgressions by others and transgressions by oneself. Objective: To examine whether these types of moral injury appraisals co-occur or whether one form is usually predominant. Additionally, to investigate what types of events (trauma, living difficulties) and outcomes (PTSD, depression, anger, suicidality) were associated with each moral injury appraisal profile. Method: Participants included 221 refugees and asylum seekers residing in Australia. Data was collected online, and via pen and paper. A latent profile analysis was used to identify profiles of moral injury appraisals. Results: Results indicated a three-profile solution: Moral Injury-Other (MI-O; 37.8%), Moral Injury Other + Self (MI-OS; 35.2%), and no moral injury (No-MI; 26.9%). MI-O and MI-OS were predicted by both trauma experience and living difficulties. MI-O and MI-OS were also associated with greater psychopathology across all outcome variables compared to No-MI. MI-OS was also associated with greater anger and depression, compared to the MI-O profile. Conclusions: The association between the moral injury appraisal profiles and traumatic events, living difficulties and psychopathology, will have important clinical implications. Un análisis de perfil latente de las valoraciones del daño moral en refugiados Antecedentes: Los refugiados frecuentemente muestran reacciones a eventos traumáticos que pueden ser conceptualizadas como daño moral (por ejemplo, el impacto de los eventos que violan valores morales importantes). Existen dos tipos de valoraciones de daño moral encontradas en los refugiados: transgresiones realizadas por otros, y transgresiones realizadas por uno mismo. Objetivo: Evaluar si estos tipos de valoraciones de daño moral suceden en simultáneo, o si un tipo es frecuentemente el predominante. Asimismo, investigar qué tipos de eventos (trauma, dificultades de vida) y consecuencias (trastorno de estrés postraumático, depresión, ira, suicidalidad) se asociaron con cada perfil de valoración del daño moral. Métodos: Los participantes fueron 221 refugiados y solicitantes de asilo residentes en Australia. Se recolectó la información en línea, y mediante lápiz y papel. Se empleó un análisis de perfil latente para identificar los perfiles de las valoraciones de daño moral. Resultados: Los resultados mostraban una solución de tres perfiles: Daño Moral-Otros (DM-O; 37,8%), Daño Moral-Otros + Uno Mismo (DM-OM; 35,2%), y sin daño moral (Sin-DM; 26,9%). El DM-O y el DM-OM podían ser predichos tanto por una experiencia traumática como por las dificultades de vida. El DM-O y el DM-OM también estaban asociados con mayor psicopatología en todas las variables evaluadas como consecuencias, en comparación con el grupo Sin-DM. El DM-OM también se asoció con mayor ira y depresión, en comparación con el perfil de DM-...

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Section: Introductionmentioning

confidence: 90%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

A latent profile analysis of moral injury appraisals in refugees

Hoffman

Liddell

Bryant

et al. 2019

European Journal of Psychotraumatology

Self Cite

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“…The DAR-5 measure (21) has demonstrated robust convergent, concurrent and discriminant validity. In addition, the recommended cut off, aligned with the 75 th percentile of the State Trait Anger Expression Inventory-2 (STAXI-2;(20)), has been associated with psychological distress and functional impairment (22,23) and utilized in numerous studies (31)(32)(33).…”

Section: Problematic Angermentioning

confidence: 99%

Magnitude of Problematic Anger and its Predictors in the Millennium Cohort

Adler

LeardMann

Roenfeldt

et al. 2020

Preprint

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Background: Problematic anger is intense anger associated with elevated generalized distress and that interferes with functioning. It also confers a heightened risk for the development of mental health problems. In military personnel and veterans, previous studies examining problematic anger have been constrained by sample size, cross-sectional data, and measurement limitations. Methods: The current study used Millennium Cohort survey data (N = 90,266) from two time points (2013 and 2016 surveys) to assess the association of baseline demographics, military factors, mental health, positive perspective, and self-mastery, with subsequent problematic anger. Results: Overall, 17.3% of respondents reported problematic anger. In the fully adjusted logistic regression model, greater risk of problematic anger was predicted by certain demographic characteristics as well as childhood trauma and financial problems. Service members who were in the Army or Marines, active duty (vs. reserves/national guard), and previously deployed with high levels of combat had increased risk for problematic anger. Veterans were also more likely to report problematic anger than currently serving personnel. Mental health predictors included posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and comorbid PTSD/MDD. Higher levels of positive perspective and self-mastery were associated with decreased risk of problematic anger. Conclusion: Not only did 1 in 6 respondents report problematic anger, but risk factors were significant even after adjusting for PTSD and MDD, suggesting that problematic anger is more than an expression of these mental health problems. Results identify potential points of early intervention and clinical treatment for addressing problematic anger in the military and veteran context.

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Moral injury, mental health and behavioural health outcomes: A systematic review of the literature

Hall

Everson

Billingsley

et al. 2021

Clin Psychology and Psychoth

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Despite a burgeoning of research on moral injury in the past decade, existing reviews have not explored the breadth of consequences and the multitude of pathways through which moral injury and potentially morally injurious experiences (PMIEs) influence mental and behavioural health outcomes. This study aimed to identify associations between moral injury on mental and behavioural health. Literature searches of psychological and medical databases were conducted through April 2020. Eligible studies measured moral injury or PMIEs, and health outcomes (e.g., depression, substance use and suicidality). Fifty-seven publications representing 49 separate samples were included. Studies examined the impact of moral injury on post-traumatic stress disorder (PTSD) (n = 43); depression (n = 32); anxiety (n = 15); suicide (n = 15); substance use (n = 14); and 'other'health outcomes, including pain, burnout, sleep disturbance and treatment-seeking behaviours (n = 11). The majority of studies found significant positive associations between moral injury-related constructs, mental health and behavioural health outcomes; however, the majority were also cross-sectional and focused on military samples. Proposed mediators included lack of social support, negative cognitions and meaning-making. Moderators included self-compassion, pre-deployment mental health education and mindfulness. Moral injury is associated with a variety of negative health outcomes. Research is needed to determine the mechanisms by which moral injury may influence these outcomes over time.

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The relationship between moral injury appraisals, trauma exposure, and mental health in refugees

Abstract: These results suggest that there may be subtypes of moral injury appraisals that are associated with different mental health outcomes. These findings have potential implications for designing treatments that address the psychological impact of the refugee experience.

Cited by 56 publications

References 66 publications

A latent profile analysis of moral injury appraisals in refugees

A latent profile analysis of moral injury appraisals in refugees

Magnitude of Problematic Anger and its Predictors in the Millennium Cohort

Moral injury, mental health and behavioural health outcomes: A systematic review of the literature

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