Moral Injury, Race-related Stress and Posttraumatic Stress Disorder in a Trauma-exposed Black Population

Abstract

Background:

Race-related stress (RRS) is an unrecognized source of moral injury (MI)—or the emotional and/or spiritual suffering that may emerge after exposure to events that violate deeply held beliefs. Additionally, MI has not been explored as a mechanism of risk for posttraumatic stress disorder (PTSD) in trauma-exposed civilians. We examined relations among exposure to potentially morally injurious events (moral injury exposure, MIE), related distress (moral injury distress, MID), and RRS in Black Americans. Potential indirect associations between RRS and PTSD symptoms via MID were also examined.

Methods:

Black Americans (n=228; 90.4% female; M_age=31.6 years. SD_age=12.8 years) recruited from an ongoing study of trauma completed measures assessing civilian MIE and MID, RRS, and PTSD. Bivariate correlations and mediation analysis were conducted to examine the role of MIE and MID in the relationship between RRS and PTSD symptom severity.

Results:

MIE was significantly correlated with cultural (r=.27,), individual (r=.29), and institutional (r=.25,) RRS; MID also correlated with cultural (r=.31), individual (r=.30), and institutional (r=.26) RRS (ps<.001). We found an indirect effect of RRS on PTSD symptoms via MID (β=.10, p<.005).

Conclusions:

All types of RRS were associated with facets of MI, which mediated the relationship between RRS and current PTSD symptoms. MI may be a potential mechanism through which RRS increases the risk for PTSD in Black individuals.

Introduction

Exposure to racism is a common experience among Black people that can lead to race-related stress (RRS). According to Jones’ (1997) tripartite model of racial stress(Cénat, 2023; Jones, 1997; Lee, Perez, Boykin, & Mendoza-Denton, 2019), RRS can occur following exposure to racism at three interconnected levels: individual, cultural, and institutional. At the individual level, Black Americans may experience RRS following overt acts of racial discrimination (e.g., being denied services based on race) or racial violence, as well as covert forms such as microaggressions (e.g., praising a person of color for being articulate) (Carter, 2007; Cenat et al., 2022; Kirkinis, et al., 2018; Small, 2020). Exposure to negative images and impressions of Black individuals (e.g., the portrayal of Black men as thugs on television), can contribute to cultural RRS (Brondolo, Blair, & Kaur, 2018; Case & Hunter, 2014) and can reinforce negative stereotypes about Black people (Gibson, Bouldin, Stokes, Lozada, & Hope, 2022). Black people may also experience institutional RRS through discriminatory policies and practices within institutions and legislative processes (e.g., law enforcement disproportionately targeting Black Americans) (Harrell, 2000). These distinct yet related race-related stressors have compounding negative psychological effects that impact the lives of Black individuals.

Exposure to more frequent race-related stressors (and ensuing stress) has been linked to adverse mental health outcomes including anxiety, depression, dissociation, and post-traumatic stress disorder (PTSD) (Cavalhieri et al., 2023; Harb et al., 2023; Mekawi et al., 2021). The cumulative effects of RRS have been associated with PTSD symptom development such as hypervigilance, avoidance behaviors, numbing, and dissociation (De Maynard, 2010; K. Kirkinis, Pieterse, Martin, Agiliga, & Brownell, 2021; Mekawi et al., 2021). Recent studies have highlighted strong associations between exposure to race-related stressors and PTSD severity. Exposure to racial discrimination significantly predicted PTSD diagnostic status over a five-year period (Sibrava et al., 2019), Furthermore, positive associations between racial discrimination and PTSD symptom severity were observed after controlling for stress inducing factors such as overall psychological distress, safety, and neighborhood crime (Holliday et al., 2020). Thus, race-related stressors may function as traumatic stressors that increase vulnerability for the development of PTSD.

Moral injury (MI) may play a mechanistic role in the increasing risk for PTSD symptoms following exposure to race-related stressors. In a recent review of the literature, MI is defined as the emotional, social, and spiritual suffering that can arise following exposure to stressful events that violate deeply held morals or values (Griffin et al., 2019). MI can result from committing, failing to prevent, or experiencing such moral violations; it may also result from betrayals by trusted people or institutions (Litz et al., 2009). Feelings of shame, guilt, anger, and disgust are frequently reported following morally injurious events (Griffin et al., 2019). Although MI has been most studied in veterans, it is a phenomenon that can emerge in civilians, including those who feel betrayed by trusted individuals or institutions (Koenig & Al Zaben, 2021; Williamson, Stevelink, & Greenberg, 2018). Two components of MI have been previously described: frequency of exposure to events appraised as morally injurious (i.e., MI exposure [MIE]) and subsequent psychological distress after such events (i.e., MI distress [MID]) (Braitman et al., 2018; Fani, et al., 2021; Fulton et al., 2023; Lathan et al., 2022; Nickerson et al., 2022). MIE and MID have been related to myriad poor mental health outcomes, from PTSD and major depressive disorder to suicidality (Fani et al., 2021; Kelley et al., 2019; Lathan et al., 2022; Lathan et al., 2023; Plouffe et al., 2023).

Although distinct constructs, it is possible that racial trauma, and consequent RRS, contribute to MI, potentially increasing vulnerability for the development of mental health disorders such as PTSD. For example, in the case of a race-related stressor, witnessing police brutality toward Black individuals can lead witnesses to feel profound betrayal by governmental institutions that are designed to protect all people. Stress that results from this morally injurious event may then contribute to vulnerability to PTSD (e.g., increased vigilance for future racist events). Although, in some instances, there may be overlap between RRS and moral injury, the two constructs can also exist independently, with a race-related stressor serving as a source of moral injury. For example, a racist event may cause RRS and may be appraised as morally injurious by one person (i.e., perceived as a violation of their moral beliefs) whereas the same race-related stressor may not be appraised as morally injurious to another person. Like other stressors that lead to MI, exposure to RRS may have multifaced, lasting, and cumulative effects on those who experience it (Small, 2020; Williams, Lawrence, & Davis, 2019). RRS has been associated with alterations in biological processes, such as immune system activation, increased response in brain regions involved with threat vigilance and emotion regulation (Busse, Yim, Campos, & Marshburn, 2017; Cuevas et al., 2020; Fani, Carter, Harnett, Ressler, & Bradley, 2021; Hertz, Unger, Cornell, & Saunders, 2005), as well as changes in cognitive processes, including increased rumination and perseverative thoughts about racist events, self-questioning/criticism and ensuing low self-esteem (Benard, Halliday, Are, Banks, & Danielson, 2021; Brondolo et al., 2018; Mereish, N’Cho, Green, Jernigan, & Helms, 2016), as well as increased social anxiety (Levine et al., 2014; Williams, Yu, Jackson, & Anderson, 1997). Together, the various antecedents of RRS function to impose an omnipresence of racism in the lives of Black Americans that may affect various aspects of functioning(Cénat, 2023; Harrell, 2000). Over time, these experiences may cause many Black Americans to challenge core beliefs about the world and the self, a common consequence of exposure to both trauma and MI(Comas-Díaz, 2016).

Despite the intuitive link between RRS and MI, evidence supporting this connection is scarce. Examining RRS as a source of MI is novel; typically, MI has been characterized by the actions or inactions of an individual that violate one’s moral code. However, racial trauma and ensuing RRS emerge consequent to the actions of external entities (individuals and/or institutions), and these actions may be experienced as morally injurious. The few studies relevant to MI in Black individuals identified racial disparities in the severity of MI in veteran populations. A seminal study conducted by Laufer, Gallops, and Frey-Wouters (1984) examined racial differences in the effects of committing and/or observing transgressive acts during wartime on Black and White veterans; Black veterans who participated in transgressive acts reported higher symptoms of MI (e.g., feelings of demoralization, guilt, anger, and hostility) than White veterans who participated in such acts. These findings were further supported by a recent study, which demonstrated that White veterans with higher socioeconomic status and education reported lower overall MI scores, suggesting that racially minoritized veterans of lower socioeconomic status and education level could potentially be at increased risk of developing MI following a transgressive act (Wisco et al., 2017). However, to our knowledge, no research has specifically examined the associations between RRS and MI in trauma-exposed Black civilians, or how this may be directly linked to mental health sequelae.

Given the lack of research explicitly examining associations between RRS and MI in Black populations, our primary goal was to investigate relationships among civilian MID and MIE and facets of RRS (i.e., individual, cultural, and institutional) in a large (N=228) community sample of Black Americans. These individuals were recruited as part of an ongoing study of trauma, the Grady Trauma Project (GTP), and had variable levels of current PTSD symptoms. A secondary goal was to examine the distress from MI as a potential mechanism underlying the relationship between RRS and PTSD symptoms in this population; as such, we tested for indirect effects of RRS on current PTSD symptoms through MID. We chose to conceptualize moral injury as a mechanism that may give rise to PTSD symptoms given both theoretical models of moral injury and some empirical research indicating that moral injury may directly contribute to other post-traumatic responses (Currier et al., 2018; D’Alessandro-Lowe et al., 2024; Litz et al., 2018; Presseau et al., 2019). Indeed, in one study, moral injury appeared to predict some PTSD symptoms (Criteria B, C, and E), but displayed a reciprocal effect with others (i.e., Criterion D symptoms also appeared to predict MID symptoms) (Currier, McDermott, Farnsworth & Borges, 2019) and in another investigation symptoms of shame and loss of trust associated with MID significantly predicted PTSD symptoms (D’Alessandro-Lowe et al., 2024). Specifically, moral injury can contribute to symptoms such as re-experiencing (Criterion B) (Litz et al., 2018) and hyperarousal (Criterion E) (Nickerson et al., 2022; Papazoglou et al., 2020), while symptoms of shame associated with MID may magnify numbing or avoidance symptoms (Criterion C) (Papazoglou et al., 2020; Presseau et al., 2019) and self-condemnation from moral injury (Currier et al., 2018) could contribute to symptoms of avoidance or anhedonia. Based on these findings and others, we chose to use MID as the mediator in our analysis.

Methods

Participants and Procedures

Two hundred and twenty-eight participants were recruited both from community advertisements and in conjunction with an ongoing study of trauma exposure and PTSD in civilians, GTP (R01AT011267; R01MH128244; R01MH117009). Participants recruited from GTP were approached by trained researchers and recruited in the general medical clinics (obstetrics/gynecology, diabetes, and internal medicine) of Grady Memorial Hospital, a large, public hospital in downtown Atlanta, Georgia, U.S.A, that provides health care for predominantly socioeconomically disadvantaged populations. After the nature of study procedures was explained and informed consent was provided, participants completed a series of self-report questionnaires (across the span of 60-to-90-minutes) with the assistance of a trained research assistant.

Participants (N =228, M_age=31.6 years; SD_age=12.8 years) identified as Black and primarily consisted of women (90.4%, N=206); clinical and demographic characteristics of the sample are provided in Table 1. Study procedures were approved by Emory University Institutional Review Board and Grady Research Oversight Committee in line with the Declaration of Helsinki.

Table 1.

Demographic and Clinical Characteristics

	% (N)
Ethnicity
Not Hispanic/Latinx	96.9 (221)
Hispanic/Latinx	2.6 (6)
Missing	0.4 (1)
Sex Assigned at Birth
Female	89.9 (205)
Male	9.6 (22)
Missing	0.4 (1)
Household Monthly Income
$0 - $249	8.3 (19)
$250 - $499	3.9 (9)
$500 - $999	12.7 (29)
$1,000 - $1,999	19.3 (44)
$2,000 or more	41.2 (94)
Missing	14.5 (33)
Highest Grade Completed in School
Less than 12th grade	6.1 (14)
12th grade or high school graduate	28.1 (64)
GED	4.8 (11)
Some college or technical school	28.9 (66)
Technical school graduate	3.1 (7)
College graduate	17.5 (40)
Graduate school	11.4 (26)
	Mean (Standard Deviation)		Range
Age	31.6 (12.8)		18–65
MIEES-C Exposure	20.4 (5.9)		5–30
MIEES-C Distress	18.9 (6.3)		5–30
IRRS-B Total	65.8 (19.9)		22–110
IRRS-B Cultural Racism	35.3 (10.2)		10–50
IRRS-B Individual Racism	17.4 (6.8)		6–30
IRRS-B Institutional Racism	13.1 (6.0)		6–30
TEI Experienced or Witnessed (N=93)	7.4 (4.0)		0–17
LEC Experienced or Witnessed (N=135)	6.1 (3.7)		0–18
PCL-5 Total	33.5 (19.2)		0–74

MIEES-C= Moral Injury Exposure and Symptom Scale-Civilian; IRRS-B= Index of Race-Related Stress-Brief; TEI= Traumatic Events Inventory; LEC= Life Events Checklist; PCL-5= PTSD Checklist for DSM-5

Measures

Race-Related Stress.

The Index of Race-Related Stress-Brief (Utsey, 1999), a 22-item self-report measure, was used to assess facets of RRS. The IRRS-B is an abbreviated version of the 46-item IRRS (Utsey & Ponterotto, 1996), and measures the emotional impact of racism encountered by Black individuals across three levels: individual, cultural, and institutional. Scores on the sub scales of the IRRS (individual, cultural and institutional) range from 0–40, with higher levels of RRS.

MI.

The Moral Injury Exposure and Symptom Scale-Civilian (MIESS-C) (Fani et al., 2021) is a 10-item self-report measure of MI in civilians (detailed description in the supplement). The scale measures frequency of exposure to potentially morally injurious events (MIE) and the degree of distress related to those events (MID).

PTSD Symptoms.

The PTSD Checklist for DSM-5 (PCL-5) (Weathers et al., 2013) is a 20-item self-report measure assessing experiences of PTSD symptoms over the previous month. Participants responded to each statement on a Likert-type scale from 0 (not at all) to 4 (extremely). Responses on the PCL-5 were related to overall experiences and not a specific event.

Trauma Exposure.

Trauma exposure was assessed with either of two measures. The Traumatic Events Inventory (Schwartz, Bradley, Sexton, Sherry, & Ressler, 2005) is a 14-item self-report measure to assess participants’ lifetime trauma exposure (n=93). The Life Events Checklist for DSM-5 (Weathers et al., 2013), a 16-item self-report measure that screens for traumatic events throughout a participant’s life (n=137). A breakdown of the number and types of traumatic events experienced as assessed by both measures is provided in the supplement.

Data Analyses

Using IBM SPSS Statistics (version 28), bivariate correlations were conducted among MIE, MID, and IRRS indices (i.e., individual, cultural, and institutional RRS). A Bonferroni-corrected statistical threshold of p < .017 was used to correct for error due to multiple comparisons with both tests (i.e., MIE, MID).

An indirect effect model was then conducted using Hayes’ SPSS PROCESS (Hayes, 2012; Hayes, Montoya, & Rockwood, 2017) macro (model 4) to determine whether there was an indirect relation between RRS (IRRS total) and current PTSD symptoms (PCL-5 total) via MID. Total race-related stress (IRRS) served as the predictor with MID as the mediator, and current PTSD symptom severity (PCL-5) as the outcome. A threshold of p < .05 was used to determine statistical significance.

Results

Greater levels of total RRS (IRRS total) were significantly associated with higher MIE r(226)=.31, p<.001, and MID r(226)=.34, p<.001. MID was positively correlated with cultural r(226)=.31, p<.001, individual r(226)=.31, p<.001, and institutional r(226)=.26, p<.001(Figure 1A) RRS. Similarly, MIE was positively correlated with cultural r(226)=.27, p<.001, institutional r(226)=.25, p<.001 and individual r(226)=.29, p<.001 (Figure 1B), RRS. Results of bivariate correlations are displayed in Table 2.

Figure 1. Correlations of moral injury exposure (a) and distress (b) with cultural, institutional, and individual race-related stress.

Figure 1A: MID positively correlated with cultural (r = .31, p < .001), institutional (r = .26, p < .001) and individual (r = .31, p < .001) race-related stress.

Figure 1B: MIE positively correlated with cultural (r = .27, p < .001), institutional (r = .25, p < .001) and individual (r = .29, p < .001) race-related stress.

Table 2.

Bivariate correlations between race-related stress, moral injury, and PTSD symptoms

Measure	1	2	3	4	5	6	7
1. MIESSC exposure	--
2. MIESSC distress	.86 **	--
3. IRRS Total	.31 **	.34 **	--
4. IRRS Cultural	.27 **	.31 **	.90 **	--
5. IRRS Individual	.29 **	.31 **	.89 **	.68 **	--
6. IRRS Institutional	.25 **	.26 **	.78 **	.51 **	.65 **	--
7.PCL5 Total	.30 **	.38 **	.31 **	.20 *	.29 **	.36 **	--

^*p < .05

^**p < .01

An indirect effect model was performed to determine if MID mediated the relationship between IRRS and PTSD symptom severity. IRRS total was positively associated with MID (path a_MID, β=.11, SE=.02, 95%CI=.07-.15) (Figure 2), and MID significantly predicted PTSD symptom severity (path b_MID, F_2,225=24.66, β=.94, SE=.19, 95%CI=.55–1.32). There was a partial indirect effect of IRRS total on PTSD symptom severity via MID (path c’_MID, β=.10, SE=.03, 95%CI=.05-.16). Sensitivity analysis revealed that inclusion of age, sex, and education as covariates did not significantly impact the indirect effect of IRRS total on PTSD symptom severity via MID (path c’_MID, β=.10, SE=.03, 95%CI=.05-.16). Additional sensitivity analysis excluding individuals who endorsed symptoms of PTSD but not a Criterion A stressor also did not significantly affect the indirect effect of IRRS total on PTSD symptom severity via MID (path c’_MID, β=.10, SE=.03, 95%CI=.05-.16). Correlations between clinical outcome and relevant demographic variables can be found in the supplement.

Figure 2: Moral injury distress mediated the relationship between race-related stress and current PTSD symptoms.

Moral injury distress (MID) mediates the relationship between race-related stress (IRRS total score) and current PTSD symptoms (PCL-5 total score). All values represent standardized betas. ** p<0.005.

Discussion

This study evaluated the relationship between MI and RRS (individual, cultural, and institutional) in a large (N=228) sample of trauma-exposed Black Americans and examined the indirect role of MI in the relationship between RRS and PTSD symptom severity. Our findings indicate that all types of RRS were significantly and strongly correlated with both MIE and MID, with the strongest associations observed with MID and individual RRS and cultural RRS. In addition, MID showed indirect effects on the relationship between RRS and current PTSD symptom severity, revealing MI as a potential mechanism through which RRS may affect vulnerability to posttraumatic sequelae.

As expected, we observed comparably strong positive associations between all types of RRS, exposure to, and distress from, morally injurious events. These findings complement a breadth of studies highlighting the immense negative psychological and emotional effects of individual, cultural, and institutional RRS on mental health in Black populations, including PTSD severity (Mekawi et al., 2021) and psychological distress (Cavalhieri et al., 2023). Notably some of strongest associations observed were between MI indices and individual and cultural RRS. To date, much of the work examining the negative effects of RRS has ignored cultural racism and focused on individual and institutional stressors. Furthermore, some studies highlight racial identity as a mediating mechanism for the effects of cultural RRS on mental health. Specifically, Gibson et al. (2022) observed that stronger racial affiliation (e.g., pride) in Black Americans mitigated the effects of cultural RRS. Sheikh et al. (2023) examined the role of racial identity on the effects of total RRS (individual, cultural, and institutional) and trauma symptoms in trauma-exposed Black women and found that higher self-reported RRS was significantly associated with higher prioritization of Black values, ideas and identity suggesting that the way Black Americans relate to their identity could significantly affect their appraisal of race-related stressors. Particularly, strong racial identity mitigated negative effects of RRS on PTSD symptomology compared to those with less regard for their racial identity. This suggests that RRS may be distinctively affected by one’s relationship with their racial identity, influencing experiences of trauma symptoms. Given that cultural racism, relates to stress associated with White Americans devaluing racial identity (e.g., deprecating the physical characteristics of Black people) (Oliver, 2001), exposure to cultural racism may violate core beliefs about aspects of the self, such as self-identity and contribute to MID; however, given that we did not examine racial identity in this study, this is merely speculative. Future studies should examine the role of racial identity as an underlying factor for the associations between various types of RRS and aspects of MI.

This study is the first to demonstrate the mediating role of MI on the relationship between RRS and PTSD symptom severity. We observed strong indirect effects of MID on the relationship between total RRS and PTSD. These findings extend our prior work, which demonstrated associations of MIE and MID with other types of trauma exposure (Fani et al., 2021; Lathan et al., 2022). Furthermore, the strength of associations with MID and RRS was greater than associations found with other types of trauma exposure (DSM-5-related traumatic events) in our prior studies, including childhood maltreatment and adult interpersonal trauma (Fani et al., 2021). These findings suggest MI could be a mechanism through which RRS enhances the risk for PTSD symptoms. Perhaps, race-related stressors underlie the effects of MI among Black individuals exposed to other types of traumas and stress (e.g., structural inequities), contributing to increased mental health disparities in Black Americans.

Feelings of anger and disgust after experiencing betrayals by institutions or trusted individuals who committed moral-violating transgressive acts are a major component of MI (Litz et al., 2009). This is salient to the Black community, given the long history of mistreatment by various institutions including governmental, academic, and medical institutions, as well as law enforcement (Chaney & Robertson, 2013; Griffith et al., 2007). The 1932 Tuskegee syphilis study is a well-known example of medical abuse experienced by the Black community in which over 600 Black American men were unknowingly being monitored for the progression of syphilis without being given proper medical attention (Manning, 2020). Such medical malpractice is observed today with Black American women being subjected to obstetric racism which includes experiencing racial discrimination (e.g., denial of proper attention) throughout pregnancy, labor, and birthing which puts the lives of the mothers at risk; overall, the average pregnancy-related death rate in the United States for women (regardless of race) is 16.7/100,000, whereas for Black American women, it was 40.8/100,000 (Petersen et al., 2019). Black Americans are also disproportionately targeted by the United States legal system, as evidenced by Black American men accounting for 30% of the incarcerated population despite comprising less than 13% of the population (Greer & Cavalhieri, 2019).

RRS from these structural inequities can have profound negative consequences on the mental health of Black Americans. Various studies have highlighted how resultant stress from these structural inequities can affect heart rate variability, cognitive control, and PTSD (Coogan et al., 2020; Hoggard et al., 2023; Utsey & Hook, 2007; Williams, Osman, Gran-Ruaz, & Lopez, 2021). Our findings add to the existing literature by providing a potential mechanism by which exposure to RRS can lead to poorer mental health outcomes. For racial and ethnically marginalized individuals, MI may be a particularly important construct to assess and target in PTSD treatment. Although PTSD and MI are often comorbid, they represent distinct constructs with overlapping but divergent psychological implications (Barnes, Hurley, & Taber, 2019; Benfer, 2023; Bryan, Bryan, Roberge, Leifker, & Rozek, 2018). PTSD and MI are both appraisal disorders that result from an adverse experience; PTSD may emerge as a response to injurious and life-threatening events, whereas MI may result from events which violate deeply held moral beliefs. Both PTSD and MI can share symptoms of social isolation, negative effects on mood or cognition, and avoidance of stimuli related to the potentially traumatic or morally injurious experience. However, while symptoms unique to PTSD include hyperarousal, numbing, and dissociation, MI is better characterized by feelings of betrayal, anger, existential crisis, disgust, guilt, and shame. These differences have significant assessment and treatment implications. PTSD screening typically utilizes the Clinician Administered PTSD Scale for DSM-5 (CAPS-5), which captures both the potentially traumatic event (Criterion A stressor) and subsequent symptoms (Criteria B-E), however, no universally accepted screening tool exists for MI. Several self-report assays have been developed to evaluate MI such as the Moral Injury Event Scale developed for military personnel (Nash et al., 2013) or for civilian populations the MIESS-C (Fani et al., 2021).

Treating fear-related symptoms of PTSD has been prioritized in PTSD clinical trials; first-line treatments for PTSD target these symptoms using exposure-based therapies (Barnes et al., 2019). However, MI may require a different focus, particularly for racially and ethnically marginalized individuals who experience a different constellation of symptoms. Furthermore, our current study builds upon earlier findings using similar populations examining the associations between PTSD and RRS (e.g., racial discrimination). In particular one study in Black women found that racial discrimination predicted the severity of PTSD symptoms after a traumatic event (Mekawi et al., 2021). Current findings fit into this context by providing a preliminary mechanism showing that RRS may effect severity of PTSD through MI. Clinicians should acknowledge the distinction between PTSD and MI symptoms while simultaneously recognizing the overlap of negative cognitions about the self, world, and future which are present in both phenomena.

Some researchers have demonstrated better treatment outcomes in addressing the combination of PTSD and MI by integrating loving-kindness meditation into cognitive processing therapy among veterans (Litz, & Carney, 2018). Loving-kindness meditations that include validation and affirmation of individuals’ emotional responses to race-related stressors may be incorporated into current evidence-based treatments. Providers should also examine the impact of previous moral violations that may hinder the client from addressing or acknowledging the symptoms of MI in treatment.

Several limitations deserve acknowledgement in this study. Our sample consisted of civilians, predominantly women, which may limit the generalizability of these findings to men or military samples. This study was not sufficiently powered to detect the potential effects of sex on our variables of interest (although sex was not correlated with any of these variables). However, future studies with a more balanced representation of sex and gender are needed to explore their potential effects on the relationships between RRS, MI, and PTSD symptoms; women have been shown to experience higher rates and severity of PTSD than men (Tolin & Foa, 2006) which could suggest differences in the appraisal of potentially traumatic events that may extend to the appraisal of potentially morally injurious events. Indeed, we have previously shown differences in dissociation between men and women as a function of both MIE and MID (Lathan et al., 2023). Additionally, women experience different forms of potentially traumatic events than men (Tolin & Foa, 2006), which may correspond to different forms of potentially morally injurious experiences (Maguen et al., 2020). A portion of our population was also recruited from a hospital setting, either seeking medical attention or accompanying those who were, which may further limit the generalizability of our findings. Our study population also included a relatively high number of people experiencing economic disadvantage, which has been linked to MIE (Schulz, 2012; Wisco et al., 2017) and is a chronic stressor that may exacerbate MID. However, we did not collect granular data on socioeconomic disadvantage and instead used educational attainment as a proxy measure; additional research into the multifaceted impact of various aspects of socioeconomic disadvantage on both MIE and MID should be explored in future studies.

The MIESS-C is also not without limitations. Although no studies to date have examined psychometric properties of this measure, it was adapted from the MIES (Nash et al., 2013) with minor changes in language to make items applicable to civilians. However, it is worth noting that another psychometrically-validated measure has suggested exposure and distress to be independent factors in MI assessment (Braitman et al., 2018). Future studies would benefit from psychometrically validating the MIE and MID subscales and ensuring test-retest and discriminant validity. Additionally, examining potential differential effects of other facets of MI not examined by the MIESS-C such as the self-directed, other-directed, and betrayal subscales described by other measures (Nash et al., 2013), would further advance our understanding of this syndrome. The MIESS-C does not index specific potentially morally injurious events, which allows for the possibility that MIE/MID and IRRS scores are colinear with another unidentified variable present in our population. Due to the prevalence of traumatic experiences in this population, the lack of an index event used in the IRRS and MIESS-C leaves open the possibility that some level of MI was not directly attributable to the RRS. Indeed, inspection of the MID model reveals that Path b (effects of MID on PCL-5) accounts for greater variance than both Paths a (RRS on MID) and Path c (RRS on PCL-5), suggesting that factors other than RRS may have contributed to overall MID burden. Future studies investigating the relationship between RRS and MI would benefit from determining if specific experiences of RRS were also appraised as morally injurious, to isolate effects unique to RRS. Although previous work has provided strong theoretical support for an association between RRS and MI (Nieuwsma et al., 2022; Wisco et al., 2017), this possibility cannot be entirely dismissed. To eliminate possible confounding factors future studies should investigate a representative cross-section of sex and socioeconomic status to ensure more robust generalizability of findings. Further, this is a cross sectional study and despite conducting mediation analysis, the current study lacks the temporal precedence to infer causation. As such, future longitudinal studies are needed to elucidate the causal mechanisms underlying the relationship between RRS, MI and PTSD symptoms.

In summary, to our knowledge, this study is the first to examine associations between various types of race-related stressors and dimensions of MI, and the first to investigate the indirect effects of MI on the relationship between RRS and current PTSD symptoms in a community-based sample of Black Americans. We observed strong, significant associations between RRS, particularly individual and cultural RRS, with MI, particularly MID. These findings suggest that MI may be a pathway through which racist experiences, and subsequent race-related stress, may influence risk for the later development of PTSD. MI warrants further examination in studies of racial trauma as a contributor to mental and physical health disparities in Black individuals. Additionally, it merits appropriate screening and attention by clinicians treating racially minoritized trauma-exposed individuals.