(PS11-55) Expressions of Moral Injury and Related Psychological Processes in a Sample of 165 Veterans

Background: Potentially morally injurious events (PMIEs) are events that violate one’s moral code or values. Veterans report a high rate of exposure to PMIEs (Maguen et al. 2020; Wisco et al. 2017). Exposure to PMIEs can result in moral pain (e.g., guilt, shame, thoughts related to blaming self). According to a contextual behavioral model of moral injury, moral injury is social, psychological, and spiritual suffering that results from inflexibly responding to moral pain (Borges et al., 2021; Farnsworth et al., 2017). Although the association between PTSD and suicide is complex and somewhat unclear (Holliday at al., 2020), there is some evidence for a positive association between moral injury-related constructs and suicidal ideation and behavior (Hall et al., 2021). Better understanding this potential relationship, and why it might occur, could be important for suicide prevention.

Methods: We conducted a secondary analysis of a sample of 165 veterans who either made a suicide attempt within the year prior to enrollment (n=98) or who never seriously considered suicide (n=67). The Expressions of Moral Injury Scale – Military Version (EMIS-M) was administered at baseline. Total scores range from 17 to 85 with higher scores indicating more severe expressions of moral injury. The Acceptance and Action Questionnaire (AAQ-II) was also administered at baseline. Total scores range from 7 to 49 with higher scores indicating greater levels of psychological inflexibility. Suicidal thoughts and behaviors were examined at six-month follow-up using the Columbia-Suicide Severity Rating Scale (C-SSRS). The Intensity of Suicidal Ideation Sub-scale of the C-SSRS measures severity of suicidal ideation. Total scores range from 0-25 with higher scores indicating more severe suicidal ideation.

Results: EMIS-M scores did not significantly predict suicide attempts at follow-up (p=0.08); however, EMIS-M scores predicted severity of suicidal ideation at follow-up. For each one point increase in EMIS-M scores there was an associated 0.21 point increase in severity of suicidal ideation (Parameter Estimate = 0.209, 95% CI: 0.142, 0.277, p< 0.0001). Psychological flexibility, as measured by the AAQ-II, mediated the relationship between expressions of moral injury and severity of suicidal ideation. Examination of a subsample (n=55) who completed the Multidimensional Psychological Flexibility Inventory (MPFI) demonstrated that this mediation was driven by a lack of contact with the present moment and a lack of committed action. Treatment approaches that seek to increase psychological flexibility may be important in mitigating moral injury as a risk factor for suicide.