RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 1

© 2019, American Psychological Association. This paper is not the copy of record and may not exactly replicate the final, authoritative version of the article. Please do not copy or cite without authors' permission. The final article will be available, upon publication, via its DOI: 10.1037/tra0000518

Moral Decision Making, Religious Strain, and the Experience of Moral Injury

Steven L. Lancaster* and Maggie Miller

Bethel University, St Paul, MN

*Corresponding Author: Department of Psychology Bethel University 3900 Bethel Drive St Paul, MN 55112 Office: 651-638-6895 Fax: 651-638-6001 Email: [email protected] RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 2

Abstract

Objective: Moral injury is the lasting psychological, spiritual, and behavioral effects of having perpetrated acts that transgress moral boundaries. Contemporary models of moral injury in military veterans examine the role of transgressive acts, moral appraisals of these acts, and the symptoms of moral injury. However, little research has examined potential pathways between these elements. The current study examined appraisals of one’s acts and religious strain as potential mediators of the link between transgressive acts and symptoms of moral injury. Further, given the inherent importance of moral cognitions in the appraisal process, we tested whether the acts to appraisals link was moderated by altruism in military veterans.

Method: An online survey, distributed using crowdsourcing software, was completed by military veterans. The survey included measures of transgressive acts, appraisals of these acts, religious strain, altruism, and self- and other-directed symptoms of moral injury. Mediation and moderated serial mediation were used to test the hypotheses.

Results: Our results indicated appraisals and religious strain significantly mediated the acts to symptoms pathway for both self- and other-directed aspects of moral injury. This pathway was significantly moderated by altruism such that a stronger link exists between acts and appraisals at higher levels of altruism.

Conclusion: Overall, these findings suggest that religious functioning and moral decision making are important aspects of the experience of moral injury and are worthy of future study.

Keywords: moral injury, transgressive act, military, religion, altruism

Clinical Impact Statement: The present study is the first to demonstrate the role of altruism in the experience of moral injury in military veterans. This study suggests that the conceptualization and treatment of moral injury should be extended to examine the impact of moral decision making in the post-transgression appraisal process.

Moral Decision Making, Religious Strain, and the Experience of Moral Injury RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 3

Military combat deployments involve exposure to environments in which there is a high probability for encountering ambiguous situations wherein one might be forced, or choose, to act against their own conscience (Frankfurt & Frazier, 2016; Nash & Litz, 2013). These conscience- violating acts, known as transgressive acts, and their negative psychological consequences, known as moral injury, have become a major emphasis of research in both the psychology and chaplaincy literatures (Farnsworth, Drescher, Evans, & Walser, 2017; Frankfurt & Frazier, 2016;

Litz et al., 2009). The most widely accepted definition of moral injury is provided by Litz and colleagues, which states that moral injury is the “lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations” (2009, p. 697). More recently, transgressive acts have been defined as “experiences that involve the violation – or transgression

– of accepted boundaries of behavior” (Frankfurt & Frazier, 2016, p. 319). While widely recognized as a problem affecting members of the military (Bryan et al. 2015; Frankfurt &

Frazier, 2016; Lancaster & Erbes, 2017; Litz et al., 2009), the nature of the relationship between transgressive acts, appraisals of these events (that is, one's thoughts, beliefs, and attitudes), and the experience of moral injury is not well understood. Further, there is a clear theoretical and empirical need for additional work on potential mediators between these acts and other aspects of the moral injury experience (Frankfurt & Frazier, 2016; Harris et al., 2011; Hodgson & Carey,

2017; Lancaster & Erbes, 2017).

Recent research in the field of moral injury has placed a focus on the role appraisals play within an individual's interpretation of transgressive acts (Farnsworth, Drescher, Nieussma,

Walser, & Currier, 2017; Frankfurt & Frazier, 2016; Lancaster & Erbes, 2017). Cognitive models, dating to the work of Beck (1970) and others, emphasize the role of appraisals in how RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 4 people process and experience life events. This general cognitive model has been widely expanded and has been useful in explaining a number of trauma-related reactions including

PTSD (Ehlers & Clark, 2000). Authors such as Farnsworth et al. (2017) and others have suggested that the appraisal is a key factor in understanding why some military members experience moral injury symptoms and others do not (Frankfurt & Frazier, 2016; Lancaster &

Erbes, 2017). A recent model of moral injury by Farnsworth and colleagues (2017, p. 392) emphasized the role of moral pain, which includes “...the occurrence of moral thoughts pertaining to culpability or judgment, or dissonance between the two.” They further argue these moral cognitions “take the form of evaluative cognitions and moral judgments” that go beyond the exaggerated or distorted cognitions seen in other disorders (p. 393). Thus, empirical and theoretical work supports the role of appraisals in the experience of moral injury and highlights how these cognitions differ from those associated with other forms of psychological distress.

Given the importance of moral appraisals cognitive models of moral injury, it is important to understand the transgressive act to moral appraisal process. The development of moral injury symptoms assumes the person has an intact moral system; otherwise an individual would not recognize an act as a moral violation (Litz et al., 2009). Models of moral decision making often emphasize that moral decisions are made intuitively, using automatic emotional responses, and then reflection and reasoning occur later (Greene, Morelli, Lowenberg, Nystrom,

& Cohen, 2008; Haidt, 2001). At the same time, other models emphasize the role of past learning, including early childhood experiences, and current environmental conditions on moral decision making (Narvaez, 2019). The environmental context could be especially influential for moral decisions made during stressful situations, such as combat, as these actions may be re- evaluated once the person is out of the stress environment. Post-deployment changes in RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 5 environment may also play an important role in the appraisal process as competing demands, values, or beliefs may lead to ongoing conflict or tensions that need to be worked out in one’s

“moral imagination” (Lacewing, 2015). Thus, this reflection process can be influenced by various persuasive or cognitive arguments and may lead to changed perspectives on the morality of one’s actions (Colby & Damon, 1992; Lacewing, 2015; Paxton, Ungar, & Greene, 2012).

Especially given the important role of character development in the military (Callina et al.,

2017), members of the military may be better equipped to use reflection in making moral judgments (Narvaez, 2010).

One specific trait that may a play a role in the appraisal process is altruism, which has been associated with how people respond to situations in which the right or correct behavior is not immediately clear (Kurzban, DeScioli, & Fein, 2012; Sarlo, Lotto, Rumiati, & Palomba,

2014). Kurzban et al. (2012) found that an individual is more likely to utilize trait altruism when the situation includes people conceptualized as kin. Given the familial-like bonds that can form during military service, the role of altruism may be a key predictor of how military veterans interpret their acts and the acts of their “family.” In response to limitations with earlier measures, Starcke, Polzer, Wolf, and Brand (2011) developed an assessment that measures one’s altruism by testing one’s responses to everyday moral situations. This measure utilizes more common events, such as “what would you do if you found a wallet?”, to assess more general levels of moral thinking. Based on the literature noted above, we predicted that trait altruism would moderate the appraisal process, such that those higher in altruism would show a stronger connection between acts and appraisals of these acts, as those higher in altruism are more likely to deem their past acts as morally wrong. RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 6

Religion is a primary way in which many individuals make moral decisions and evaluate novel moral dilemmas (Graham & Haidt, 2010), and most major religions emphasize a moral self-commitment in which individuals should take responsibility for their behavior (Narvaez,

2010). Further, as about three out of every four members of the military indicate that religion plays an impactful role within their life (Koenig et al., 2017), it is important to examine how the role of religion impacts the relationship between moral appraisals and symptoms of moral injury.

Spiritual conflict is seen as a core component of moral injury and has been incorporated in a range of theoretical models of this construct (Farnsworth et al., 2017; Jinkerson, 2017). A growing body of research suggests that religious beliefs, especially religious strain, can contribute to the experience of distress when an individual is faced with traumatic or stressful events (Koenig, Youssef, Oliver, et al., 2018; Smith, McCullough, & Poll, 2003; Worthington &

Langberg, 2012). Religious strain can involve a range of experiences including anger at a deity, religious fear and guilt, or rifts with other members of a religious tradition (Exline & Rose,

2005). Religious strain has been associated with a range of negative experiences, including physical distress as well as high psychological distress such as shame, depression, and suicidal thoughts (Ano & Vasconcelles, 2005; Evans et al., 2018; Koenig, Youssef, Ames, et al., 2018;

Smith et al., 2003; Volk & Koenig, 2018). Theoretical work has also highlighted the important role that religion can play in meaning making, especially in response to difficult life events

(Harris, Park et al., 2015). Exposure to transgressive experiences may lead to extensive meaning making efforts, and significant aspects of these efforts may rely on religious and spiritual aspects of one’s identity. More recently, Evans and colleagues (2018) showed that religious and spiritual struggles fully mediated the relationship between transgressive act exposure and negative mental health outcomes in military veterans. They argued that transgressive experience may lead to RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 7 distress as people wrestle with questions about their religious worldview, issues related to ultimate goodness, and tension with their religious community. Thus, religious strain has been linked to the experience of moral injury, and especially as a mediator after stressful life events.

There is significant evidence that transgressive acts and symptoms of moral injury can be divided into two broad categories: self-directed and other-directed (Currier et al., 2017; Jordan,

Eisen, Bolton, Nash, & Litz, 2017; Lancaster, 2018; Schorr et al., 2018, Yeterian et al., 2019).

For example, Yeterian and colleagues (2019) described these categories as “(a) transgressions by individuals [self] and (b) situations in which individuals are the victim of, or witness to, others’ transgressions [other].” In their survey of clinician experiences with moral injury, common self- directed events included “seeing immoral acts and doing nothing to stop them, killing within the rules of engagements, and making a mistake or failing in a task that resulted in harm to others.”

Common other-directed events included “seeing others harmed as a result of decisions made or not made by someone else, and seeing others treat the helpless with disrespect.” This distinction is supported by work that has shown different emotional responses to these two types of transgressions, with guilt and shame more strongly associated with self-directed forms, and anger more strongly associated with other-directed (Jordan et al., 2017; Lancaster, 2018). Yeterian and colleagues found that veterans exposed to self-directed events experience themselves as unlovable and unforgivable, while those exposed to other-directed events see themselves as incompetent (2019). This incompetence was particularly related to their ability to respond to future moral challenges. Finally, Currier and colleagues (2017) performed a factor analysis using the Expressions of Moral Injury Scale - Military Version and found the symptoms of moral injury separated into self- and other-directed symptom. Thus, our study examined two models of RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 8 moral injury symptoms: one focused on self-directed experiences and the other focusing on other-direct experiences.

The aims of the current paper were to examine the mediating roles of appraisals and religious strain on the relationship between transgressive acts and symptoms of moral injury with a specific focus on the moderating role of trait altruism within military veterans. Specifically, we hypothesized that appraisals would mediate the relationship between acts and symptoms.

Second, consistent with Evans et al. (2018), we hypothesized that religious strain would mediate the relationship between appraisals and symptoms. Finally, we hypothesized a serial moderated mediation model (Figure 1), in which the mediated relationship between acts and appraisals was moderated by altruism such that a stronger relationship exists as altruism increases.

Methods

Participants

United States military veterans who had served in a combat zone (or received combat pay) during the post-9/11 era completed an online survey (N = 120). The sample was primarily male (85.0%) and Caucasian (81.2%) with a mean age of 34.53 (SD = 6.11). Other common ethnicities were Hispanic (n = 9, 7.5%), African-American/Black (n = 6, 5.0%), and Asian-

American (n = 3, 2.5%). Army was the most commonly reported branch of service (n = 70,

58.3%), then Navy (n = 18, 15.04%), then Air Force (n =16, 13.3%), then Marine Corps (n = 15,

12.5%), and then Coast Guard (n = 1, .8%).

Procedure

An online survey was administered via Qualtrics software and distributed using

Amazon’s Mechanical Turk (MTurk) system, an online crowdsourcing marketplace. Online crowd-sourced methods of data collection have been used successfully to recruit veterans (Duffy, RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 9

Jadidian, Douglass, and Allan, 2015; Forkus, Breines, and Weiss, in press; Morgan and

Desmaris, 2017). Further, veteran data collected using Mturk has shown consistency with other forms of data collection (Lancaster, 2018). The project was described as a study of “military related attitudes and how you make decisions.” Participants were recruited using two methods.

First, we made the survey available to those who had self-reported military experience within the

MTurk system. Second, we created a screening process for general MTurk workers and made the project available to those who successfully screened in to the study. The screening process involved a survey asking potential participants to identify which, if any, of ten “high risk” jobs they had worked, one of which was military service. Those who indicated military service were then asked to indicate in which branch they had served (including an option of “I am not a veteran”), whether they had received combat pay, and to which areas they had been deployed.

Only participants who reported serving in a military branch, experiencing a deployment, and reporting a valid service area were retained and offered the informed consent to participate in the current study (full text of screening measures are available from the first author). Given the possibility that transgressive act exposure and appraisals of these acts may differ in those who volunteered versus were drafted for military service, we included only those who served in post

9/11 combat deployments. Those who selected “I am not a veteran” or who endorsed an ineligible or impossible area of deployment (non-existent conflicts were included to identify those who were randomly or falsely responding) were screened out and not allowed to participate. Participants recruited using both methods were asked to complete the same survey measures and the survey procedures were identical.

Upon completing the electronic informed consent, participants were first asked to complete either measures of moral decision making (one of which was used in the current study) RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 10 or measures of transgressive acts and symptoms of moral injury. The order of presentation of moral decision making and transgressive act measures was counterbalanced. They were then asked to complete two measures not used in the current project (assessing anger, guilt, and shame), then a measure of religious functioning, and finally a demographics questionnaire.

Means and standard deviations for all participants are presented in Table 1. Participation averaged around 15 minutes and participants were paid $1.50 after completing the survey, which is consistent with other MTurk projects. A total of 434 individuals accessed the survey. Of those, 160 did not report a combat deployment, 74 reported deployments prior to 9/11/2001, 54 did not report a transgressive act, nine opted out before completing the deployment questions, and nine opted out after reading the consent form. An additional group (n = 9) was removed due to either random responding or completing the survey at a rate that strongly suggests they did not read the items carefully (e.g. less than five minutes) and one participant was removed due to being a multivariate outlier (tested using Mahalanobis Distance at p < .01). The study methods and procedures were approved by the Institutional Review Board at Bethel University.

Measures

Transgressive Acts Scale. To assess exposure to transgressive acts, we modified the scale used by Lancaster (2018). These modifications were made in response to feedback from reviewers of the previous scale as well as experts in the field of moral injury who suggested a wider range of events would better capture the range of potentially morally injurious events. Our modifications included adding additional potentially transgressive acts as well as assessing appraisals for each act. The scale lists 14 specific events that a veteran may have experienced, as well as an open text box for a participant to add any additional experiences. A few example items include, “I sometimes treated civilians more harshly than necessary,” “I saw/was involved RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 11 in violence that was out of proportion to the even,” and “My actions directly resulted in death to an enemy combatant. Said another way, I killed or think I killed someone in combat.” The survey was set up to be reactive to participant reporting. Thus, if a participant indicated “yes” to an item, they were asked to answer two appraisal items. These items read “Keeping in mind your personal beliefs about what is right and wrong, to what extent did the actions of your comrades during this event (or these events) seem wrong?” and “Keeping in mind your personal beliefs about what is right and wrong, to what extent did your actions during this event (or these events) seem wrong?” Thus, each item assessed experience of an act as well as appraisals of other’s and one’s own actions during the event. Only participants who reported at least one act were retained in the current study. Consistent with Lancaster and Erbes (2017), a total score was calculated for Self and Other appraisals, and this number was divided by the total number of transgressive acts so the ratings of “wrongness” could be compared across participants.

Participants were then asked to keep these transgressive acts in mind as they responded to the remaining measures.

Everyday Moral Decision-Making Task. The Everyday Moral Decision-Making Task

(EDMD; published in Starcke, Polzer, Wolf, & Brand, 2011) was developed to assess overall levels of altruism as measured by how one reacts to common moral dilemmas. This task presents 20 dilemmas, each with a more altruistic and a more egotistic option. For example, “As you pass by an elementary school, you recognize a heroin injection needle lying on the pavement. Do you pass by without taking any action to dispose of the needle?” Half of the items are scored in the altruistic direction and half in the egotistic. The egotistic items are then reverse scored to create a scale of altruism; higher scores (range is 0-20) indicate more altruistic responses. Cronbach’s alpha for these items in the current project was .80. RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 12

Religious Comfort and Strain Scale. The Religious Comfort and Strain Scale (RCSS;

Exline, Yali, & Sanderson, 2000) was used to measure religious strain. This measure assesses the degree to which religious aspects of one’s life lead to religious strain. Sample items include

“Fear of God’s punishment,” “Difficulty trusting God,” and “Disagreement with something that your religion or church teaches.” Consistent with Harris, Leak, Dubke, and Voecks (2015), we utilized a 0 “not at all” to 7 “extremely” version of the scale. In the current sample, internal consistency was .83 for religious strain.

Expressions of Moral Injury Event Scale – Military Version. The EMIS was developed by Currier and colleagues (2017) to provide an empirical measure of “warning signs” of the presence of a moral injury. The measure was developed using a staged process and was then compared to a range of outcomes in military samples. The final version involved 17 items that are rated on a scale from 1 “strongly disagree” to 5 “strongly agree.” The items were developed to assess a range of warning signs, including doubting one’s ability to make moral decisions, withdrawing from being around others, doubting the motives of those in authority, and believing that one is unforgivable. Currier and colleagues used exploratory factor analysis to further separate the measure into two subscales: self-directed moral injury (e.g. “I feel guilt about things that happened during my military service that cannot be excused.”) and other-directed moral injury (e.g. “When I look back on my military service, I feel disgusted by things that other people did.”). Their results demonstrated strong internal consistency (Cronbach’s alpha above .9 for both scales across two studies) as well as strong test-retest reliability across a 6-month time span (.74 for self-directed and .80 for other-directed). In the current study, the Cronbach’s alpha was .93 for the self-directed items and .90 for the other-directed items.

Data Analysis Procedure RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 13

We began by running a correlational analysis to examine the relationship between the variables before continuing with other analyses (Table 1). We next conducted a series of mediational analyses using the PROCESS macro (Hayes, 2017). First, we tested the mediating role of other-focused appraisals on the relationship between transgressive acts and other-focused symptoms of moral injury (PROCESS model 4). We then tested the mediating role of religious strain on the relationship between appraisals and other-focused symptoms of moral injury.

Finally, we tested a moderated serial mediational model (see Figure 1, PROCESS model 83) to examine possible mediation by both appraisals and religious strain and whether this mediational pathway was moderated by levels of trait altruism. We then repeated this process for self-focused appraisals and self-focused symptoms of moral injury.

Results

Test of Other-Focused Symptoms

In accordance with the data analysis plan, we tested the mediation of acts and symptoms by appraisals using a bootstrapped analysis in the PROCESS macro set for 5,000 bootstraps with

95% confidence intervals. Results indicated a significant direct effect of acts on appraisals, b

= .10, SE = .04, p = .01, and a direct effect of appraisals on symptoms of moral injury, b = 4.00,

SE = .64, p < .001. The PROCESS macro further provides a test of the direct and indirect effect of the predictor on the outcome (Hayes, 2017). In the current analysis, we found that that there was a direct effect of acts on symptoms, b = .72, SE = .30, p < .001, as well as a significant indirect effect via appraisals that was statistically different from zero (indirect effect = .39, 95%

CI [.09, .77]). We then tested the mediation of appraisals and symptoms by religious stain using the same method. Results indicated a significant direct effect of appraisals on religious strain, b =

7.61, SE = 1.51, p < .001, and a significant direct effect of religious strain on symptoms of moral RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 14 injury, b = .16, SE = .04, p < .001. Further there was a significant direct effect of appraisals on symptoms, b = 3.21, SE = .65, p < .001, as well as an indirect effect via religious strain (indirect effect = 1.19, 95% CI [.57, 1.95]).

Next, we tested the moderated serial mediation model presented in Figure 1. The number of transgressive acts and altruism interactively predicted levels of appraisals (see Table 2 for full regression results). Probing this interaction further showed that those at low levels of altruism

(one SD below the mean) demonstrated no relationship between the number of acts and appraisals of those acts, effect = .02, SE = .04, p = .65. However, for those high in altruism (one

SD above the mean) there was a strong and positive relationship between acts and appraisals, effect = .23, SE = .05, p < .001. We then examined the various indirect effects from transgressive acts to symptoms of moral injury. Consistent with the findings above, the indirect effect from acts to appraisals to symptoms was significantly moderated, as demonstrated by a nonzero index of moderated mediation (Hayes, 2017; effect = .09, 95% CI [.03, .16]). Probing this moderation revealed that the indirect effect was not significant at low levels of altruism (indirect effect = .06,

95% CI [-.23, .33]), but was significant at higher levels of altruism (indirect effect = .73, 95% CI

[.33, 1.23]). The indirect effect of acts to religious strain to symptoms showed a significant indirect effect as well (indirect effect = .30, 95% CI [.11, .55]). Finally, the indirect path from acts to appraisals to strain to symptoms demonstrated a significant index of moderated mediation

(effect = .02, 95% CI [.007, .051]). Probing this interaction showed no indirect effect at low levels of altruism (indirect effect = .02, 95% CI [-.06, .12]), but was significant and positive for those higher in altruism (indirect effect = .21, 95% CI [.07, .42]). This model demonstrated full mediation as the direct effect from transgressive acts to symptoms of moral injury was not significantly different from zero in this final model (effect = .41, SE = .27, p = .13). RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 15

Test of Self-Focused Symptoms

We then repeated the above analyses to examine possible mediation and moderation of the path from transgressive acts to self-focused symptoms. The test of mediation of acts to symptoms via appraisals indicated a significant direct effect of acts on appraisals, b = .11, SE

= .04, p = .002, and a direct effect of appraisals on symptoms of moral injury, b = 4.35, SE = .56, p < .001. Results further supported a direct path between acts and symptoms, b = .82, SE = .22, p

< .001, as well as a significant indirect path (indirect effect = .47, 95% CI [.19, .78]). In the next analysis, we found a significant direct effect of appraisals on strain, b = 8.81, SE = 1.56, p

< .001, and a significant direct effect of strain on self-focused symptoms of moral injury, b = .11,

SE = .03, p = .001. There was a significant direct effect of appraisals on symptoms, b = 3.96, SE

= .61, p < .001, and a significant indirect effect (effect = .95, 95% CI [.36, 1.69].

In terms of the full moderated serial mediation, the number of transgressive acts and altruism interactively predicted ratings of appraisals (see Table 3 for full regression results).

Probing this interaction further showed that those at low levels of altruism (one SD below the mean) demonstrated no relationship between number of acts and appraisals of those acts, effect =

.05, SE = .04, p = .18. However, for those high in altruism (one SD above the mean) there was a strong and positive relationship between acts and appraisals, effect = .20, SE = .05, p < .001).

Next, we examined the various indirect effects from transgressive acts to symptoms of moral injury. Consistent with the findings above, the indirect effect from acts to appraisals to symptoms was significantly moderated as demonstrated by a nonzero index of moderated mediation (effect

= .07, 95% CI [.01, .14]). Probing this moderation revealed that the indirect effect was not significant at low levels of altruism (indirect effect = .20, 95% CI [-.09, .52]), but was significant at higher levels of altruism (indirect effect = .76, 95% CI [.36, 1.16]). The indirect effect of acts RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 16 to strain to symptoms showed a significant indirect effect as well (indirect effect = .16, 95% CI

[.02, .34]). Finally, the indirect path from acts to appraisals to strain to symptoms demonstrated a significant index of moderated mediation (effect = .01, 95% CI [.00, .03]). Probing this interaction showed no indirect effect at low levels of altruism (indirect effect = .03, 95% CI

[-.01, .11]), but was significant and positive for those higher in altruism (indirect effect = .12,

95% CI [.02, .29]). This model demonstrated only partial mediation as the direct effect from transgressive acts to self-focused symptoms of moral injury remained significant in the full model (effect = .65, SE = .23, p = .005).

Discussion

The primary aim of the current project was to examine a model of moral injury that separately assessed transgressive acts, appraisals of these acts, and symptoms of moral injury.

Key to this model was the hypothesized role of altruism as a moderator of the relationship between transgressive acts and appraisals, and the hypothesis that religious strain would mediate the relationship between appraisals and moral injury. Overall, the model was supported by the data and shows important mediators and moderators of the association between transgressive acts and symptoms of moral injury.

Consistent with a large body of work in the field of traumatic stress studies and morally injurious experiences (Ehlers & Clark, 2000; Lancaster & Erbes, 2017), appraisals of one’s experiences mediated the relationship between transgressive acts and symptoms of moral injury.

This finding is also consistent with a number of theoretical models of moral injury (Frankfurt &

Frazier, 2016; Kopacz et al., 2016, Litz et al., 2009) that place attributions of events as an important predictor of long-term outcomes. Our work extends previous efforts by Held and colleagues (2017), who showed that negative posttraumatic cognitions mediate the relationship RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 17 between appraisals of moral wrongdoing, as measured using the Moral Injury Event Scale, and psychopathology. As noted by Frankfurt and Frazier (2016), the Moral Injury Event Scale confounds the experience of a transgressive act and one’s appraisal of that event. The method used in the current paper allowed us to separate out these elements and more specifically examine the role of appraisals. Future studies should examine the role of other posttraumatic cognitions, such as those measured by the PostTraumatic Cognitions Inventory, to more fully understand how the appraisal process explains negative outcomes after transgressive acts.

In our study, religious strain was also a significant predictor of both self-directed and other-directed symptoms of moral injury and mediated the association between appraisals and symptoms. This is in line with other literature that has highlighted the role of religious strain in psychological functioning, especially moral injury (Drescher et al., 2011; Currier, Holland, &

Malott, 2015; Jinkerson, 2016; Evans et al., 2018). Specifically, Currier, Holland, and Malott

(2015) noted that transgressive acts cause one to question God or cut themselves off from those who will help them with their coping process. Drescher and Foy (2008) suggested traumatic combat experiences can lead to a combination of degeneration of faith and increased spiritual confusion, which can lead to a negative religious coping style. Further, veterans who are experiencing struggles with issues related to religion and spirituality show more psychological and social impairment than veterans who are not (Berg, 2011; Fontana & Rosenheck, 2005; Park et al., 2017).

Consistent with our predictions, altruism moderated the relationship between transgressive acts and cognitive appraisals of these acts. These findings are consistent with the idea that one’s general moral evaluations, that is their “moral compass,” would make a significant contribution to this model (Drescher & Foy, 2008, p. 99). While promising, RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 18 additional work is needed to better understand the relationship between one’s moral decision- making process and how one evaluates past actions. For example, the EDMD is limited in that it lacks a contemplation component that is necessary for the psychological processing of moral decisions (Gunia, Wang, Huang, Wang, & Murnighan, 2012) and is focused on everyday experiences, which may limit its ability to assess the moral decisions made during stressful situations (Yousef et al., 2012). Given the relatively new status of the field, additional research is needed to better understand who experiences acts as negative or wrong, and for which types of events this occurs.

The results of the current study point to the need for additional research in a number of domains. First, additional study of the role of moral decision making in moral injury would help us better determine who might be at risk for developing moral injury, the nature of moral injury itself, as well as how to treat those who are experiencing this form of distress. Powers (2017) noted that combat can lead to moral flattening and thus change one’s orientation to one’s own morality. Bowker and Levine (2016) expressed a similar sentiment in that a soldier may realize their moral sacrifice during combat was not worth it or was wrongly aimed. Recent work in moral decision making has also emphasized the importance of “moral imagination,” as part of moral deliberation, in which individuals specifically examine alternative viewpoints or perspectives (Narvaez, 2010). It is not clear at this time the degree to which members of the military shift in terms of their beliefs about the morality of past actions. Longitudinal studies that are able to assess moral decision making or moral development before and after combat would help examine some of these possibilities. Longitudinal studies would also allow for changes in moral appraisals across time, which may be relevant for both our understanding of moral injury as well as how to help veterans experiencing these symptoms. Given the challenges inherent in RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 19 this type of work, additional progress could be made by continuing to examine possible mediators of the transgressive act to moral appraisal relationship, including other indicators of moral development or decision making. A further area of research is to examine aspects of the deployment experience. For example, does the presence or experience of moral injury differ between those who experienced direct combat versus those who did not? Even more specifically, whether the context of the transgressive act – such as during a combat engagement or not – should be examined in future studies.

Our study is consistent with a growing body of research that has shown a link between religious strain and negative outcomes after trauma, including moral injury. Indeed, Evans and colleagues (2018) highlighted this area and called for additional research. Further a number of interventions for moral injury address religious functioning as part of treatment (Harris et al.,

2011; Koenig et al., 2017; Maguen & Litz, 2012; Steenkamp et al., 2011; Worthington &

Langberg, 2012). What is less clear is how these religious factors may affect the experience of moral injury. For example, does religious strain lead to a sense of loss of purpose or meaning that then creates additional negative outcomes? Or perhaps the religious strain creates a real or perceived gap between a person and their faith community, which further erodes adaptive functioning? It is also not clear how pre-existing levels of religious belief may differentially impact this process. That is, do transgressive acts affect those with religious beliefs more because they have violated a sacred belief, or is religious belief protective as the person is able to seek forgiveness or some other cognitive benefit? Two recent papers suggest future studies in moral injury should carefully control for the religious backgrounds of military veterans. First,

Koenig and colleagues (2017) presented a model that suggests the development of moral injury may take different pathways or forms based on one’s religious belief status. A more recent paper RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 20 by Currier, Foster, and Isaak (2019) further identified “psychological and spiritual subtypes of moral injury” using latent class analysis. Their project identified a spiritual subtype of moral injury that may be more likely to experience religious strain in comparison to a more psychological subtype. As our paper was not designed to separate out these various groups, a necessary next step would be to examine separate mediational pathways based on those who report or do not report religious beliefs.

In addition to examining how moral decision making and religious belief may help us understand transgressive acts, appraisals, and symptoms, it is also necessary to better understand how these areas impact each other. Harris, Park, Currier, Usset, and Voecks (2015) examined how level of spiritual development may play a role in how a member of the military experiences combat. So future studies may need to go beyond religious/spiritual strain and incorporate how the person makes sense of their faith. Additional research is also needed to better understand how religious belief may impact the moral decision-making process for transgressive acts. These important interactions and feedback loops will lead to a more complete description of this process.

The results of the current paper are tempered by a number of limitations that should be considered in future research. While scale development continues for measures of moral injury symptoms, additional work is needed to develop validated measures of the acts and appraisal processes that may lead to moral injury. Further, while the use of crowd-sourced data for military veterans is gaining popularity, screening for this population is a challenge. Future work should continue to refine these crowed-sourced methods as well as attempt to replicate these findings using other methods such as VA or active-duty military samples. Further, given the methods used in the paper, the sample size was smaller than in previous projects (such as those RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 21 using the Marine Resiliency Study). Larger samples in future projects may allow for a more nuanced examination of relevant moderators such as level of combat exposure, rank, or gender.

The study is limited further by the lack of data on military rank or time in service; future studies may benefit from the inclusion of these covariates. The current study is also limited in that the role of moral emotions is not included in this model. Given the importance of moral emotions in moral decision making (de Graaf, Schut, Verweij, Vermetten, & Giebels, 2016) as well as in the link between transgressive acts and negative outcomes, including moral injury symptoms and

PTSD (Lancaster, 2018), future studies should incorporate these aspects of experience more fully. While our mediational model is consistent with the theoretical work in the field, the cross- sectional nature of our data does not allow us to test for temporal or causal aspects of the model.

Finally, given our focus on the role of religious functioning, a screen for religious beliefs may have been appropriate. However, given that one could have religious strain even if not reporting any religious beliefs (for example, if they had been rejected by their faith community or family due to their religious worldview), using a sample with a range of beliefs may be most appropriate. The project is strengthened by the use of a sample with a range of military branches, demographic characteristics, and deployment experiences.

In summary, our study looked to identify possible mediators for one’s likelihood of reporting symptoms of moral injury after experiencing transgressive acts. Our data were consistent with a model in which transgressive acts and religious strain mediate the relationship between acts and symptoms, while the relationship itself was impacted by the level of trait altruism. Next steps within this field include continuing to look at the role of moral decision making, examining other measures of this construct, and testing how religion and other meaning- making strategies may interact with methods of moral decision making. These steps will allow RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 22 for a better understanding of why some individuals may be more susceptible to experiencing symptoms of moral injury as well as what can be done within the therapeutic setting to help reduce these symptoms. RUNNING HEAD: MORAL JUDGMENT AND MORAL INJURY 23

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