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Journal of Military, Veteran and Family Health logoLink to Journal of Military, Veteran and Family Health
. 2023 Feb 10;9(2):6–18. doi: 10.3138/jmvfh-2022-0057

Negative cognitions in the context of suicidality after exposure to military-related potentially morally injurious events

Stephanie A Houle a, Joseph Inhaber a, Rakesh Jetly b, Andrea R Ashbaugh a
PMCID: PMC13293170  PMID: 42533954

Lay Summary

Moral injury (MI) refers to the psycho-spiritual consequences of events that deeply transgress a person’s core moral beliefs and values. Such events are reportedly common in the military context, and strong associations have been demonstrated between exposure to potentially morally injurious events (PMIEs) and suicidality. This study explored differences in negative cognitions between treatment-seeking Canadian Armed Forces members and Veterans with and without current suicidal thoughts and behaviours (STBs), all of whom reported current distress in response to a PMIE. Those exhibiting STBs reported stronger negative beliefs about the self. Scores for event-related guilt cognitions and self-blame were similar across individuals with and without STBs. Individuals reporting STBs also displayed higher depression and symptoms of posttraumatic stress disorder. The results suggest that severity of mental health symptoms and negative self-evaluations may be most pertinent in their association with suicidality in the MI context. Results remain preliminary, however, and additional research is needed to properly examine how event and self-related evaluations affect suicidality after PMIEs.

Key words: Canadian Armed Forces, depression, guilt, military, moral injury, negative cognitions, PMIE, posttraumatic stress disorder, potentially morally injurious events, PTSD, shame, suicidal thoughts and behaviours, Veterans

Abstract

Introduction:

Consistent associations are found between exposure to potentially morally injurious events (PMIEs) and suicidal thoughts and behaviours (STBs). Studies examining cognitions after PMIEs have focused on those describing one’s role in the event (e.g., “I did something wrong”) rather than those describing sense of self (e.g., “I am a bad person”). Stable internal attributions (e.g., “I did a bad thing because I’m a bad person”) are shown to be particularly psychologically harmful; therefore, this is an important limitation. The study explored differences in negative cognitions in those reporting and not reporting STBs after a PMIE.

Methods:

This study is a secondary analysis of data from a treatment-seeking sample of Canadian military members and Veterans reporting distress after a PMIE (N = 55). Participants completed clinician-administered interviews on STBs and questionnaires measuring negative cognitions.

Results:

More than half (n = 30) of participants endorsed current STBs, and 20.0% (n = 11) reported previously attempting suicide. There were no differences in cognitions related to hindsight/responsibility, wrongdoing, lack of justification, self-blame, or negative cognitions about the world. Participants with STBs reported more negative cognitions about the self than those without current STBs.

Discussion:

Results suggest that negative cognitions focusing on stable features of the self, rather than on events, may be more important in their association with STBs after a PMIE. This is consistent with the notion that shame, rather than guilt, is more problematic in psychopathology and STBs.

Introduction

Moral injury (MI) is an emerging construct in the military mental health literature and describes the distress that can arise after events that deeply transgress one’s moral values.1 Examples of such events include killing in combat, witnessing atrocities, and being betrayed by authority figures.1,2 Among previously deployed Canadian Armed Forces (CAF) personnel, the prevalence of such events is high, ranging between 58% and 84%.3,4 Military personnel and Veterans also commonly report exposure to potentially morally injurious events (PMIEs) outside deployment (e.g., sexual assault that occurs on base).5–7 Although MI is not itself a psychiatric diagnosis, the pattern of distress characteristic of MI includes emotional consequences, such as feelings of guilt, shame, and anger, cognitive consequences in the areas of spirituality and identity (e.g., loss of previously held beliefs, difficulties with meaning-making, loss of trust), and behavioural consequences, such as social isolation.1,7–9

In addition to MI and other deleterious outcomes such as posttraumatic stress disorder (PTSD) and depression, research on the mental health impact of PMIE exposure has shown robust associations with suicidality.9–12 A recent meta-analysis found that PMIEs were a common factor linking depression and PTSD to suicidal ideation in the military context.13 Some PMIEs may also present different risks regarding suicidality. For instance, one study conducted with a nationally representative sample of U.S. Veterans showed that events involving betrayal and those involving perpetration of a moral transgression were associated with increased odds of suicidal ideation.14 Another study of treatment-seeking active-duty U.S. soldiers found that acts of perpetration were most significantly associated with suicidal ideation.10

Other risk factors for military suicidality include depression and PTSD — two notable psychological problems strongly associated with PMIE exposure.9,12,15–17 Feelings of guilt, which are reportedly common in the aftermath of PMIEs and are a salient feature of both depression and PTSD, have been associated with suicidality in military and non-military samples. One study found that guilt was a predictor of suicidal ideation in a clinical outpatient military sample,18 even when controlling for depression and PTSD symptoms. Moreover, there is evidence that trauma-related guilt plays a mediating role in the association between PTSD and suicidal ideation in military populations, highlighting a potential pathway to military suicide.19,20 Studies also show that certain trauma-related cognitions — in particular, negative beliefs about the self (e.g., I am weak, I have permanently changed for the worse) in the aftermath of trauma — play a mediating role in the association between PTSD and suicidality.21,22

Central to MI theory is the assertion that an inability to incorporate morally transgressive experiences into pre-existing schemas of the self, others, and the world can prompt psychological distress.1 Examples identified in qualitative studies to date highlight negative changes in personal beliefs about identity, moral capacity, trust, and spirituality, among others, in relation to PMIEs.7,23–25 Furthermore, preliminary evidence exists that certain trauma-related guilt cognitions are more salient among active-duty and recently retired U.S. military personnel in response to exposure to PMIEs compared with exposure to life-threatening events.26 These cognitions include hindsight bias, or a sense that one could have changed the outcome of the event, and thoughts about wrongdoing and self-blame.26 Still, associations among specific cognitions and suicidal thoughts and behaviours (STBs; e.g., the desire to die, impulses to harm or kill oneself, preparations made for a suicide attempt) in the context of MI research have only begun to be examined empirically. Studies conducted so far have shown, for instance, that overidentification with one’s failings moderated the relationship between self-directed MI and STBs.27 Another study showed that beliefs about entrapment (e.g., a desire to escape a situation in which escape is perceived to be impossible) mediated the association between suicidal ideation and self- and betrayal-based MI.28 Finally, although not examined in the context of STBs, other-and betrayal-focused MI were associated with increased beliefs of thwarted belongingness,29 a key factor in the interpersonal model of suicidality.30 Notably, effect sizes across these studies are in the moderate to large range, suggesting that these cognitions may be particularly relevant to STBs in the context of MI. Moreover, many of the cognitions examined so far in reference to STBs and MI appear to be related to global, stable, and internal attributions and beliefs related to connectedness with others — key cognitive themes implicated in theoretical models of both MI and suicidality.1,31 However, as noted earlier, most findings have yet to be replicated, and additional research is needed to bolster the evidence base as to the associations among MI and suicidality, including how particular cognitions may interact with these patterns of distress.

In addition to the general scarcity of research on this subject, most studies on the associations among STBs and MI have been conducted outside of Canada, mainly in the United States. Thus, associations among PMIE exposure, MI, and suicidality in the Canadian context remain largely unknown. This is an important limitation, given the CAF’s differing culture and history of military operations compared with the United States. For instance, the United States’s military ethos has been described as centered around a warrior identity and beliefs about defending against the nation’s enemies, whereas Canada’s public-facing military doctrine has historically emphasized peacekeeping and humanitarian intervention.32,33 A better understanding of the mechanisms underlying suicidality in the CAF context is particularly warranted given its recent commitments to suicide prevention.34

The objective of this study was to explore differences in a range of negative cognitions occurring in the aftermath of PMIEs between individuals reporting and not reporting STBs. This was done through a secondary analysis of data previously collected from treatment-seeking current and former members of the CAF experiencing distress in response to a PMIE. The study reports on the severity of mental health symptoms and qualities of PMIE exposure and combat exposure between participants reporting and not reporting STBs. The authors examined three types of trauma-related guilt cognitions (hindsight bias and personal responsibility, lack of justification, and wrongdoing) and three types of posttraumatic cognitions (negative beliefs about the self, negative beliefs about the world, and self-blame) as indexed to participants’ most distressing PMIE. Although this study was exploratory, the specificity of this sample, the rigorous method by which suicidality was assessed, and the range of posttraumatic cognitions assessed in response to PMIEs extend the understanding of STBs among treatment-seeking military personnel and Veterans, providing important context for the development of further research.

Methods

Participants

Participants were recruited between November 2017 and August 2019 from two clinics in Ottawa, Ontario, Canada, specializing in the treatment of occupational stress injuries. Participants were eligible to participate if they were 1) a current or former member of the military, 2) reported distress associated with experiences they had in the military (i.e., according to assessment reports, presenting distress was related to military experiences and not solely a product of factors external to this context, such as family or health problems), 3) were not currently experiencing symptoms consistent with psychosis or mania, and 4) were not at imminent risk of committing suicide or homicide. All participants included in this study reported currently experiencing distress resulting from a PMIE, which was determined on the basis of the following screening questions: During your time in the military, have you ever experienced or learned about events that damaged your beliefs or expectations about the kind of person you are, the kind of world we live in, or right and wrong ways to treat people? Are you currently experiencing psychological distress as a result of this experience? Full details of the recruitment procedure can be found in the original study publication.7

Data for this study were gathered from 55 participants who completed all study measures. An additional four individuals participated in the study but were excluded from analysis for the following reasons: did not complete all study interviews or questionnaires (n = 1), failed to endorse any PMIE (n = 1), did not express any current PMIE-related distress (n = 1), and experienced cognitive deficits that severely affected responding (n = 1). Participants were divided into two groups, the STB group (n = 30) and the no-STB group (n = 25), based on whether or not they endorsed STBs on the Mini International Neuropsychiatric Inventory (MINI), described next.

Measures

Mini International Neuropsychiatric Inventory

The MINI (version 7.0.2) is a structured diagnostic interview used to assess for 17 of the most common psychiatric disorders in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5).35 The suicidality module of the MINI was used to assess for current STBs. Questions (yes or no) are arranged using branching logic. The suicidality module contains 27 questions assessing current suicidality, including suicidal ideation, intent, planning, impulses, behaviours, and past attempts. Each question is ascribed points that are totalled to determine suicidality severity. Participants who indicated a past suicide attempt more than two years before the study (i.e., were considered in remission) and who did not endorse any other STBs were coded into the no-STB group. Otherwise, participants with a total score higher than 1 were assigned to the STB group, per the MINI’s scoring guidelines.

Trauma-Related Guilt Inventory

The Trauma-Related Guilt Inventory (TRGI) is a 32-item scale that assesses feelings and cognitions associated with guilt about a traumatic event.36 Responses are rated on a five-point scale ranging from 0 (not at all true) to 4 (extremely true). While completing the TRGI, participants were instructed to answer questions about a PMIE they identified as being most distressing to them currently. The TRGI has five sub-scales, three of which assess specific trauma-related guilt cognitions, which were examined in this study. These three sub-scales are Hindsight-bias/Responsibility (e.g., “I could have prevented what happened”), Wrongdoing (e.g., “I did something that went against my values”), and Lack of Justification (e.g., “What I did was completely justified”). Final TRGI sub-scale scores were computed by averaging the raw score of the appropriate items. In this sample, the internal consistency of these sub-scales was acceptable (αHindsight-bias/Responsibility = 0.88, αWrongdoing = 0.72, αLack of Justification = 0.85).

Posttraumatic Cognitions Inventory

The Posttraumatic Cognitions Inventory (PTCI) is a 36-item scale used to assess cognitions about a traumatic event.37 Responses are rated on a seven-point scale ranging from 1 (totally disagree) to 7 (totally agree). The PTCI has three sub-scales: Negative Cognitions about the Self (e.g., “I can’t trust that I will do the right thing”), Negative Cognitions about the World (e.g., “I can’t rely on other people”), and Self-blame (e.g., “The event happened because of the way I acted”). While completing the PTCI, participants were instructed to answer questions about their most distressing PMIE. Final PTCI sub-scale scores were computed by averaging the raw score of appropriate items. In this sample, internal consistency for all the sub-scales was acceptable (αNegative Cognitions about the Self = 0.97, αNegative Cognitions about the World = 0.92, αSelf-blame = 0.85).

Posttraumatic Stress Disorder Checklist for DSM-5

The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) is a 20-item self-report measure of PTSD symptoms.38 Items are rated on a five-point scale ranging from 0 (not at all) to 4 (extremely). Participants were instructed to keep in mind their index PMIE as they completed the PCL-5. Participants’ raw scores on each of the PCL-5 items were summed to obtain a final PCL-5 score. In this sample, internal consistency of the PCL-5 was excellent (α = 0.94).

Beck Depression Inventory-II

The Beck Depression Inventory-II (BDI-II) is a 21-item self-report inventory of depressive symptoms over the previous two weeks.39 Each item is rated on a four-point scale ranging from 0 to 3. Total scores describe an individual’s severity of depression. Participants’ raw scores on each of the BDI-II items were summed to obtain a final BDI-II score. Internal consistency in this sample was excellent (α = 0.94).

Moral Injury Event Scale

The Moral Injury Event Scale (MIES) is a nine-item self-report measure used to assess the degree of PMIE exposure on a scale ranging from 1 (strongly disagree) to 6 (strongly agree).40 A recent psychometric study among CAF personnel found that the MIES is most reliably composed of two sub-scales, Transgression-Self (e.g., “I am troubled by having acted in ways that violated my own morals or values”) and Transgression-Other (e.g., “I am troubled by having witnessed others’ immoral acts”).41 Participants’ raw scores on each of the MIES items were summed to obtain a total MIES score. Final sub-scale scores were computed by averaging the raw score of the appropriate items. Both sub-scales had acceptable internal consistency in this sample (αTransgression-Self = 0.92, αTransgression-Other = 0.73).

Combat Experiences Scale

The Combat Experiences Scale (CES) is a 17-item measure used to assess the frequency at which participants were exposed to various combat situations (e.g., “I fired my weapon at enemy combatants”).42 Participants were asked to respond to CES items on a scale ranging from 1 (never) to 6 (daily or almost daily). Participants’ raw scores on each of the CES items were summed to obtain a final CES score.

Procedure

Full details of the original study procedure can be found in the original study publication.7 Briefly, after providing informed consent, participants completed a structured interview, providing categorical details about their experiences of PMIEs, including the type (e.g., self- or other-based transgressions) and the context of the index PMIE (e.g., peacekeeping operation, on base). Of the PMIEs endorsed, participants identified an index PMIE (defined as the most distressing PMIE). Afterward, participants completed the MINI and then the questionnaires. All interviews were administered by SA Houle, a trained clinician.

Data analysis

To assess the primary objective of examining differences in negative cognitions between STB and no-STB participants, a series of exploratory independent-samples t-tests were conducted to examine differences in trauma-related guilt cognitions (TRGI; i.e., Hindsight-Bias/Responsibility, Wrongdoing, Lack of Justification), and other posttraumatic cognitions (PTCI; i.e., Self-Blame, Negative Cognitions about the Self, and Negative Cognitions about the World). These measures were not examined in the original study. The authors also examined differences in PMIE exposure (MIES), combat exposure (CES), depressive symptoms (BDI-II), and PTSD symptoms (PCL-5) across the two groups to provide additional contextual details of the sample. The Benjamini-Hochberg correction was applied to reduce the risk of Type 1 error associated with multiple comparisons. Before running statistical analyses, assumptions underlying the independent-samples t-test were verified. Data were confirmed to be normally distributed, and Levene’s test revealed no violations in homogeneity of variance between groups on any measures. Pearson correlations were also calculated to examine associations among the dependent variables, and χ2 tests were conducted to examine any differences in PMIE type across STB groups.

Results

Sample characteristics

Sample characteristics are shown in Table 1. Participants were mostly white and male. Of the total sample, 20% (n = 11) reported at least one previous suicide attempt. The number of attempts among those with previous attempts ranged from one to three (mean = 2.00, SD = 0.78). Scores on the MINI indicated that, among participants in the STB group, 40% (n = 12) reported a mild range of STBs, 13% (n = 4) reported a moderate range of STBs, and 47% (n = 14) reported a severe range of STBs.

Table 1.

Participant characteristics (N = 55)

Characteristic n (%)*
No-STB group (n = 25) STB group (n = 30)
Age, mean (SD) 49.40 (7.87) 46.00 (12.03)
Gender
 Male 22 (88.0) 23 (76.7)
 Female 3 (12.0) 6 (20.0)
 Trans woman 0 (0.0) 1 (3.3)
Ethnicity
 White 23 (92.0) 28 (93.3)
 Black 1 (4.0) 0 (0.0)
 Other (mixed race) 1 (4.0) 2 (6.7)
Marital status
 Never married, single 1 (4.0) 2 (6.7)
 Married or living together 16 (64.0) 22 (73.3)
 Separated or divorced 6 (24.0) 4 (13.3)
 Remarried 2 (8.0) 2 (6.7)
Employment
 Full time 13 (52.0) 9 (30.0)
 Part time 0 (0.0) 3 (10.0)
 Irregular employment 1 (4.0) 1 (3.3)
 Unemployed 2 (8.0) 1 (3.3)
 Retired 7 (28.0) 9 (30.0)
 Full disability 2 (8.0) 7 (23.3)
Branch of service
 Canadian Army 17 (68.0) 17 (56.7)
 Royal Canadian Navy 0 (0.0) 5 (16.7)
 Royal Canadian Air Force 5 (20.0) 7 (23.3)
 Other (e.g., Special Forces) 3 (12.0) 1 (3.3)
Duty status
 Regular Force 23 (92.0) 25 (83.3)
 Reserve Force 2 (8.0) 5 (16.7)
Duty
 Combat arms 11 (44.0) 8 (26.7)
 Combat support 10 (40.0) 14 (46.7)
 Combat service support 4 (16.0) 8 (26.7)
Rank†
 Pte-MCpl/OS-MS 6 (24.0) 14 (46.7)
 Sgt-CWO/PO2-CPO1 14 (56.0) 9 (30.0)
 Lt-Capt/SLt-Lt(N) 1 (4.0) 6 (20.0)
 Maj/LCdrand above 4 (16.0) 1 (3.3)
Years of service
 <5 1 (4.0) 2 (6.7)
 6–10 0 (0.0) 7 (23.3)
 11–15 6 (24.0) 3 (10.0)
 16–20 7 (28.0) 6 (20.0)
 21–25 0 (0.0) 3 (10.0)
 >26 11 (44.0) 9 (30.0)
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Note: Age range 28–73 y.

*

Unless otherwise indicated.

†

Army, Air Force/Navy ranks.

Pte-MCpl/OS-MS = Private to Master Corporal/ Ordinary Seaman to Master Seaman; Sgt.-CWO/PO2-CPO1 = Sergeant to Chief Warrant Officer/Petty Officer, 2nd Class to Chief Petty Officer, 1st Class; Lt-Capt/ SLt-Lt(N) = Lieutenant to Captain/Sub-Lieutenant to Lieutenant (Navy); Maj/LCdr and above = Major/Lieutenant-Commander and above.

All data pertaining to the characteristics of participants’ index PMIEs were collected via structured interview and are shown in Table 2. There were no differences between the STB and no-STB groups regarding index PMIE type (i.e., self-transgression, other-transgression, or mixed event; see Table 2) or combat exposure (see Table 3). Scores on the MIES also did not differ between groups for total score or for either sub-scale (see Table 3). The authors could not statistically compare the STB and no-STB groups on the context of the index PMIE or the worst part of the index PMIE because some cell counts were less than five.

Table 2.

Characteristics of index PMIE by group

Characteristic n (%)
 χ2 ρ
No-STB group (n = 25) STB group (n = 30)
Type 0.66 0.72
 Self-transgression 3 (12.0) 6 (20.0)
 Other-transgression 16 (64.0) 17 (56.7)
 Mixed 6 (24.0) 7 (23.3)
Context of index PMIE* N/A N/A
 Warlike operation 4 (16.0) 10 (33.3)
 Peacekeeping 9 (36.0) 8 (26.7)
 Humanitarian 1 (4.0) 0 (0.0)
 Border protection 0 (0.0) 0 (0.0)
 In garrison/on base 9 (36.0) 11 (36.7)
 Other 1 (4.0) 1 (3.3)
Worst part of index PMIE N/A N/A
 You thought that you could be seriously injured or killed 0 (0.0) 2 (6.7)
 You thought that someone else could be seriously injured or killed 1 (4.0) 3 (10.0)
 The sights, sounds, and smells of the event (e.g., seeing dead bodies) 3 (12.0) 1 (3.3)
 A friend was killed 3 (12.0) 3 (10.0)
 A unit member was killed 0 (0.0) 2 (6.7)
 A non-combatant was killed 0 (0.0) 1 (3.3)
 You failed to fulfill an important duty, obligation, or moral standard 3 (12.0) 5 (16.7)
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Note: χ2 tests were not performed for Index PMIE context or Worst part of index PMIE because of lower-th an-acceptable cell counts.

*

n = 1 missing from the no-STB group.

PMIE = potentially morally injurious event; STB = suicidal thoughts and behaviours; N/A = not applicable.

Table 3.

Negative trauma-related cognitions, psychological symptoms, and combat and PMIE exposure among participants reporting and not reporting STBs

Measure Mean (SD)
 t53 (95% Cl) Cohen’s d
No-STB group (n = 25) STB group (n = 30)
TRGI
 Hindsight-bias/responsibility 1.06 (1.00) 1.25 (1.11) 0.64 (−0.387 to 0.767) 0.17
 Wrongdoing 1.56 (1.08) 1.71 (0.97) 0.55 (−0.405 to 0.705) 0.15
 Lack of Justification 1.58 (1.26) 1.88 (1.33) 0.84 (−0.405 to 1.005) 0.23
PTCI
 Negative Cognitions about the Self 2.73 (1.41) 3.74 (1.36) 2.71* (0.259 to 1.761) 0.73
 Negative Cognitions about the World 4.65 (1.52) 5.46 (1.13) 2.28 (0.093 to 1.528) 0.62
 Self-blame 2.41 (1.70) 2.45 (1.38) 0.11 (−0.793 to 0.873) 0.03
MIES
 Total 33.92 (9.39) 37.67 (10.58 1.38 (−1.713 to 9.213) 0.37
 Transgression-other 4.38 (1.15) 4.56 (1.19) 0.56 (−0.457 to 0.817) 0.15
 Transgression-self 3.00 (1.74) 3.72 (1.77) 1.51 (−0.234 to 1.674) 0.41
 CES 33.44 (15.74) 28.47 (9.52) −1.44 (−1.935 to 11.882) 0.39
 PCL-5 31.52 (16.27) 48.63 (15.71) 3.96* (8.438 to 25.782) 1.07
 BDI-II 18.80 (11.51) 28.30 (11.84) 3.00* (3.150 to 15.850) 0.81
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*

p < 0.05, Benjamini-Hochberg corrected.

TRGI = Trauma-Related Guilt Inventory; PTCI = Posttraumatic Cognitions Inventory; MIES = Moral Injury Event Scale; PCL-5 = Posttraumatic Stress Disorder Checklist for DSM-5; BDI-II = Beck Depression Inventory-II.

Symptoms of PTSD and depression

Compared with the no-STB participants, STB participants scored significantly higher on both the BDIII and the PCL-5 (see Table 3). The magnitude of the effect was large for both the BDI-II and the PCL-5.

Differences in negative cognitions

Regarding guilt-related cognitions, the results revealed no differences between the STB and no-STB participants on the Hindsight-Bias/Responsibility, Wrong-doing, or Lack of Justification sub-scales of the TRGI (Table 3). Regarding the PTCI, scores on the Negative Cognitions about the Self sub-scale were higher in the STB group than in the no-STB group, yielding a moderate effect size (Table 3). A moderate effect size was also observed for Negative Cognitions about the World, although the results were not statistically significant after the Benjamini-Hochberg correction was applied. Scores on the Self-Blame sub-scale did not differ between groups.

Bivariate associations among all measures examined are shown in Table 4.

Table 4.

Pearson correlations between dependent variables of interest

Variable 1 2 3 4 5 6 7 8 9 10 11
TRGI
 1. Hindsight-bias/Responsibility – – – – – – – – – – –
 2. Wrongdoing 0.62* – – – – – – – – – –
 3. Lack of Justification 0.32† 0.33† – – – – – – – – –
PTCI
 4. Negative cognitions about the self 0.48* 0.37‡ 0.05 – – – – – – – –
 5. Negative cognitions about the world 0.29† 0.21 0.04 0.64* – – – – – – –
 6. PTCI-self-blame 0.62* 0.37‡ 0.14 0.43* 0.43* – – – – – –
MIES
 7. Total 0.53* 0.45* 0.44* 0.40‡ 0.37‡ 0.55* – – – – –
 8. Transgression-other 0.20 0.24 0.32* 0.12 0.44* 0.39‡ 0.73* – – – –
 9. Transgress ion-self 0.60* 0.44* 0.37‡ 0.47* 0.16 0.47* 0.83* 0.22 – – –
 10. PCL-5 0.42‡ 0.26 0.07 0.81* 0.58* 0.42‡ 0.50* 0.29† 0.48* – –
 11. BDI-II 0.49* 0.21 0.04 0.83* 0.56* 0.40‡ 0.36‡ 0.16 0.39‡ 0.81* –
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*

p < 0.001.

†

p<0.05.

‡

p<0.01.

TRGI = Trauma-Related Guilt Inventory; PTCI = Posttraumatic Cognitions Inventory; MIES = Moral Injury Event Scale; PCL-5 = Posttraumatic Stress Disorder Checklist for DSM-5; BDI-II = Beck Depression Inventory-II.

Discussion

The aim of this study was to explore differences in negative cognitions between treatment-seeking CAF members and Veterans with and without STBs, all of whom were currently reporting distress in response to a PMIE. The authors also examined between-groups differences in mental health symptoms and PMIE and combat exposure. Although the sample size was small, the results suggest that certain types of cognition may be more common among individuals experiencing STBs in the aftermath of military PMIEs. Results thereby provide some preliminary insights to be examined in future research regarding the mechanisms underlying MI and STBs in the military.

Although some previous research demonstrated that guilt-related cognitions are associated with PMIE exposure and military suicidality,19,20,26 the authors observed non-meaningful effect sizes and no statistical differences in scores on the Hindsight-Bias/Responsibility, Lack of Justification, Self-Blame, or Wrongdoing sub-scales between participants with and without STBs. Only scores on Negative Cognitions about the Self, as measured with the PTCI, was found to be moderately higher among participants reporting STBs.

The findings are in line with existing theory and evidence in several ways. First, it is well documented that guilt and shame can be differentiated on the basis of how morally transgressive behaviours are cognitively appraised. Guilt is thought to arise from unstable attributions of immoral behaviour and is characterized by thoughts such as “I did a bad thing.” In contrast, shame is represented by stable, internal attributions of immoral behaviour and is characterized by thoughts such as “I did a bad thing because I am a bad person.”43,44 Although the distress characteristic of MI may indeed involve intense feelings and related thoughts of both guilt and shame,1 and research has shown that both guilt and shame mediate the associations between depression, PTSD, and STBs,18 it may be that the internal attribution of cognitions (e.g., “I did a bad thing because I am a bad person”) is what increases severity of psychopathology, including STBs.44 For instance, theories of both MI and depression purport that attributions about events and behaviours that are internal, stable, and global — a cognitive style central to shame — are particularly psychologically harmful.1,44,45 The notion that shame is a more potent driver of suicidality, compared with guilt, has also been supported empirically.46 Although the influence of shame on suicidality was not explicitly examined in this study, the Negative Cognitions about the Self sub-scale of the PTCI does capture cognitions typical of shame. Additional studies using larger samples and more sophisticated analyses are needed to further examine the role of guilt and shame-related cognitions in the context of MI and suicidality.

The authors also observed that both severity of depression and PTSD were elevated in the STB group compared with the no-STB group. This finding is consistent with previous research demonstrating associations between these mental health problems and STBs in the military context.16,18 Interestingly, one recent study found that negative beliefs about the self was predictive of suicidal ideation even after controlling for the effect of depression and PTSD,21 suggesting that these beliefs may exert a unique influence on STB. Indeed, it is possible that these beliefs, along with depression and PTSD, serve as mediators in the association between PMIE exposure and STB. Unfortunately, the authors did not have the power to test similar associations, but Pearson correlations showed strong associations among these three factors. Still, the extent to which such patterns may be observed specifically in the context of PMIEs and MI should be further investigated. For instance, it is not uncommon for individuals experiencing clinically significant mental health problems in response to traumatic events to report distress pertaining to a devalued view of self, attributable to their mental health diagnosis and loss of functioning (i.e., self-stigmatization).47 Indeed, a recent factor analysis of the PTCI conducted with trauma-exposed military Veterans demonstrated that beliefs about one’s inability to cope with emotions (i.e., “perceived inability to cope”) was an important sub-factor of the Negative Cognitions about the Self sub-scale — one that was significantly correlated with both depression and PTSD.48 Thus, it may be that PMIEs’ capacity to prompt mental health problems, in general, is more important in their association with suicidality than particular negative cognitions associated with PMIEs. Future research should consider examining which aspects of negative beliefs about the self are most strongly related to STBs in the context of MI.

The authors found no differences in combat or PMIE exposure, nor in PMIE type, between participants reporting and not reporting STBs. Future research is needed to further explore this question, especially given previous evidence that certain types of PMIEs may be differentially associated with hopelessness, guilt, and shame — important factors in suicidality.10,28,49

Interestingly, the Negative Cognitions about the World sub-scale of the PTCI also displayed a moderate effect size in the analyses, indicating elevated scores on this scale in the STB group. The α level for this test was not significant after correction was applied, despite initially meeting the threshold for statistical significance. Previous research supports the relevance of these types of cognitions in the association between PTSD and suicidality;50 however, the impact of such beliefs in the context of MI and suicidality has only begun to be evaluated. For instance, although studies among Veterans have shown that both self- and other-directed MI is associated with suicidality, other-directed MI, in which negative beliefs about the world may be most relevant, may be more strongly associated with suicide attempts.10,27 Consistent with this notion, research showed that other-directed MI is associated with beliefs related to thwarted belongingness, a key factor in the interpersonal model of suicidality.31 Considering the small sample size and conservative approach to statistical interpretation, studies using larger samples and more sophisticated analyses may have a higher likelihood of detecting associations between other-directed negative cognitions and suicidality in the context of MI.

In addition, given that the PTCI’s Negative Cognitions about the World sub-scale is composed of items related to both negative attributions of others (e.g., “People are not what they seem,” “People cannot be trusted”) and of the world more generally (e.g., “The world is a dangerous place”), future research may consider separately assessing various internal, stable, and global attributions of other people and the world because such findings may provide additional insights into mechanisms underlying suicidality in the MI context. Still, negative self-based, rather than other-based, cognitions may remain most important in their association with suicidality, and this hypothesis should also be considered in future studies.

Limitations and future directions

A strength of this study is its application of a comprehensive, clinician-administered interview assessing suicidality. Unfortunately, as a result of the limited sample size, it lacked the power required to perform more sophisticated analyses that may have provided further insights into the mechanisms underlying associations between PMIE exposure and suicidality in this sample. The authors, therefore, opted for an exploratory approach to analysis. Findings reported here should be used as a starting point to develop hypothesis-driven studies examining associations among negative cognitions, MI, and suicidality in larger samples, which would produce findings that are more generalizable. In addition, this sample was one of convenience and did not extend beyond treatment-seeking individuals who responded favourably to the recruitment approach. Moreover, one of the exclusion criteria was imminent suicide risk; therefore, current findings may not apply to individuals at higher risk of dying by suicide. Additional studies with more heterogeneous samples are needed to further assess the question of how negative cognitions and suicidality are associated in the aftermath of PMIEs.

Another important limitation is that, although participants were asked to index their responses on the cognitions measures to a most distressing PMIE, the authors were unable to assess the extent to which these events may have included classic features of trauma (e.g., life threat, sexual violence). Indeed, a large proportion of participants in the sample met criteria for PTSD; therefore, the extent to which the associations observed can be separated from the influence of other potentially traumatic and diagnostic features present in the sample is unknown. Future research would benefit from further exploration of the psychosocial impact of PMIEs that do and do not include elements of trauma.

Nevertheless, the findings add to a small but growing evidence base on the patterns of distress associated with military PMIE exposure, and they prompt important hypotheses for future research. In particular, longitudinal studies are needed to better elucidate the mechanisms involved in the development of mental health problems and suicidality in the aftermath of PMIEs; the moral quality of distress characteristic of these events may elicit consequences that are particularly difficult to contend with. For example, a recent study of previously deployed military personnel demonstrated that MI was characterized by cognitions pertaining to themes of atonement, difficulty forgiving and trusting others, and self-judgement, and PTSD was characterized by cognitions relating to threat of harm and forgiveness of the situation.51 The extent to which such cognitions may be associated with STBs has yet to be examined. In addition, analyses examining guilt- and shame-related cognitions across time as they relate to PMIE exposure and suicidality may provide an indication as to whether an individual’s internalization of trauma-related guilt cognitions may lead to the shame and hopelessness underlying suicidality. A better understanding of these links is likely to improve efforts relevant to MI prevention and intervention.

Additional research is also needed to examine patterns of MI and STBs among individuals of diverse gender and identity backgrounds. Given the sample size and gender distribution of this study, the authors were unable to perform such analyses. Addressing these questions is highly warranted, not only because characteristics such as gender, race, and sexual orientation may be associated with increased risk of PMIE exposure (e.g., female service members are more likely to experience betrayal-based military sexual trauma),52 but also because the rate of STBs among minority populations and those with diverse identity backgrounds tend to be higher.53

Conclusion

Treatment-seeking, PMIE-exposed CAF members and Veterans exhibiting STBs reported stronger negative beliefs about the self and, to a non-significant degree, negative beliefs about the world. In contrast, beliefs of guilt or self-blame as they pertained to a PMIE were similar across individuals with and without STBs. Individuals reporting STBs also reported higher levels of depression and PTSD symptoms than those without STBs. The results suggest that severity of mental health symptoms and negative self-evaluations may be most pertinent in their association with suicidality in the MI context. Results remain preliminary, however, and additional research is needed to properly examine how event- and self-related evaluations affect suicidality in the aftermath of PMIEs.

Biographies

Stephanie A. Houle, PhD, recently graduated from the University of Ottawa in clinical psychology. Her research focuses on the phenomenology, clinical utility, and healing of moral injury in the military context.

Joseph Inhaber is a PhD student in clinical psychology at the University of Ottawa. His research is focused on the phenomenon of moral injury and seeks to better understand the factors associated with people’s perceptions of potentially morally injurious events.

Col. (retd) Rakesh Jetly, OMM, CD, MD, is an associate professor of psychiatry at the University of Ottawa. Until his retirement in 2021, he was Senior Psychiatrist and Mental Health Advisor to the Canadian Armed Forces Surgeon General. He was appointed The Canadian Forces Brigadier Jonathan C. Meakins, CBE, RCAMC Chair in Military Mental Health in 2015. He has published numerous articles in professional journals and presents nationally and internationally on posttraumatic stress disorder, moral injury, and operational psychiatry.

Andrea R. Ashbaugh, PhD, CPsych, is an associate professor in the School of Psychology at the University of Ottawa, with expertise in research on anxiety, memory, and cognition. Her current research program focuses on examining features of potentially morally injurious events from an experimental paradigm.

Funding Statement

No funding was received for this article.

Competing Interests

The authors have nothing to disclose.

Ethics Approval

The original study approved by the Research Ethics Boards at The Royal Ottawa Health Care Group (REB no. 2017011) and the University of Ottawa (REB no. A06-17-02), and the secondary analysis plan was approved by the Research Ethics Board at the University of Ottawa (H-05-21-7024).

Informed Consent

N/A

Registry and Registration No. of the Study/Trial

N/A

Animal Studies

N/A

Peer Review

This manuscript has been peer reviewed.

References

  • 1.Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009;29(8):695–706. 10.1016/j.cpr.2009.07.003. Medline:19683376 [DOI] [PubMed] [Google Scholar]
  • 2.Shay J. Achilles in Vietnam: combat trauma and the undoing of character. Illustrated edition. New York: Scribner; 1994. [Google Scholar]
  • 3.Hansen KT, Nelson CG, Kirkwood K. Prevalence of potentially morally injurious events in operationally deployed Canadian Armed Forces members. J Trauma Stress. 2021;34(4):764–72. 10.1002/jts.22710. Medline:34146353 [DOI] [PubMed] [Google Scholar]
  • 4.Sareen J, Cox BJ, Afifi TO, et al. Combat and peacekeeping operations in relation to prevalence of mental disorders and perceived need for mental health care: findings from a large representative sample of military personnel. Arch Gen Psychiatry. 2007;64(7):843–52. 10.1001/archpsyc.64.7.843. Medline:17606818 [DOI] [PubMed] [Google Scholar]
  • 5.Frankfurt SB, DeBeer BB, Morissette SB, et al. Mechanisms of moral injury following military sexual trauma and combat in post-9/11 U.S. war veterans. Front Psychiatry. 2018;9:520. 10.3389/fpsyt.2018.00520. Medline:30450058 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Cotter A. Sexual misconduct in the Canadian Armed Forces Regular Force, 2018. [Internet]. Ottawa: Government of Canada; 2019. [cited 2022 July 18]. Available from: https://www150.statcan.gc.ca/n1/pub/85-603-x/85-603-x2019002-eng.htm#n14-refa. [Google Scholar]
  • 7.Houle SA, Vincent C, Jetly R, et al. Patterns of distress associated with exposure to potentially morally injurious events among Canadian Armed Forces service members and Veterans: a multi-method analysis. J Clin Psychol. 2021;77(11):2668–93. 10.1002/jclp.23205. Medline:34224575 [DOI] [PubMed] [Google Scholar]
  • 8.Currier JM, Farnsworth JK, Drescher KD, et al. Development and evaluation of the Expressions of Moral Injury Scale — Military Version. Clin Psychol Psychother. 2018;25(3):474–88. 10.1002/cpp.2170. Medline:29282787 [DOI] [PubMed] [Google Scholar]
  • 9.Griffin BJ, Purcell N, Burkman K, et al. Moral injury: an integrative review. J Trauma Stress. 2019;32(3):350–62. 10.1002/jts.22362. Medline:30688367 [DOI] [PubMed] [Google Scholar]
  • 10.Bryan AO, Bryan CJ, Morrow CE, et al. Moral injury, suicidal ideation, and suicide attempts in a military sample. Traumatology. 2014;20(3):154–60. 10.1037/h0099852. [DOI] [Google Scholar]
  • 11.Bryan CJ, Bryan AO, Roberge E, et al. Moral injury, posttraumatic stress disorder, and suicidal behavior among National Guard personnel. Psychol Trauma. 2018;10(1):36–45. 10.1037/tra0000290. Medline:28581315. [DOI] [PubMed] [Google Scholar]
  • 12.Hall NA, Everson AT, Billingsley MR, et al. Moral injury, mental health and behavioural health outcomes: a systematic review of the literature. Clin Psychol Psychother. 2021;29(1):92–110. 10.1002/cpp.2607. Medline:33931926 [DOI] [PubMed] [Google Scholar]
  • 13.Williamson V, Stevelink SAM, Greenberg N. Occupational moral injury and mental health: systematic review and meta-analysis. Br J Psychiatry. 2018;212(6):339–46. 10.1192/bjp.2018.55. Medline:29786495 [DOI] [PubMed] [Google Scholar]
  • 14.Wisco BE, Marx BP, May CL, et al. Moral injury in U.S. combat veterans: results from the National Health and Resilience in Veterans Study. Depress Anxiety. 2017;34(4):340–7. 10.1002/da.22614. Medline:28370818 [DOI] [PubMed] [Google Scholar]
  • 15.Guerra VS, Calhoun PS. Examining the relation between posttraumatic stress disorder and suicidal ideation in an OEF/OIF veteran sample. J Anxiety Disord. 2011;25(1):12–8. 10.1016/j.janxdis.2010.06.025. Medline:20709493 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Ramsawh HJ, Fullerton CS, Mash HBH, et al. Risk for suicidal behaviors associated with PTSD, depression, and their comorbidity in the U.S. Army. J Affect Disord. 2014;161:116–22. 10.1016/j.jad.2014.03.016. Medline:24751318 [DOI] [PubMed] [Google Scholar]
  • 17.Nazarov A, Fikretoglu D, Liu A, et al. Greater prevalence of post-traumatic stress disorder and depression in deployed Canadian Armed Forces personnel at risk for moral injury. Acta Psychiatr Scand. 2018;137(4):342–54. 10.1111/acps.12866. Medline:29504125 [DOI] [PubMed] [Google Scholar]
  • 18.Bryan CJ, Morrow CE, Etienne N, et al. Guilt, shame, and suicidal ideation in a military outpatient clinical sample. Depress Anxiety. 2013;30(1):55–60. 10.1002/da.22002. Medline:23077111 [DOI] [PubMed] [Google Scholar]
  • 19.Cunningham KC, Farmer C, LoSavio ST, et al. A model comparison approach to trauma-related guilt as a mediator of the relationship between PTSD symptoms and suicidal ideation among veterans. J Affect Disord. 2017;221:227–31. 10.1016/j.jad.2017.06.046. Medline:28654847 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Tripp JC, McDevitt-Murphy ME. Trauma-related guilt mediates the relationship between posttraumatic stress disorder and suicidal ideation in OEF/ OIF/OND Veterans. Suicide Life Threat Behav. 2017;47(1):78–85. 10.1111/sltb.12266. Medline:27273459 [DOI] [PubMed] [Google Scholar]
  • 21.Horwitz AG, Held P, Klassen BJ, et al. Posttraumatic cognitions and suicidal ideation among veterans receiving PTSD treatment. Cogn Ther Res. 2018;42(5):711–19. 10.1007/s10608-018-9925-6. Medline:30505042 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.McLean CP, Zang Y, Zandberg L, et al. Predictors of suicidal ideation among active duty military personnel with posttraumatic stress disorder. J Affect Disord. 2017;208:392–98. 10.1016/j.jad.2016.08.061. Medline:27810723 [DOI] [PubMed] [Google Scholar]
  • 23.Held P, Klassen BJ, Hall JM, et al. “I knew it was wrong the moment I got the order”: a narrative thematic analysis of moral injury in combat veterans. Psychol Trauma. 2018;11(4):396–405. 10.1037/tra0000364. Medline:29723032 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Purcell N, Koenig CJ, Bosch J, et al. Veterans’ perspectives on the psychosocial impact of killing in war. Couns Psychol. 2016;44(7):1062–99. 10.1177/0011000016666156. [DOI] [Google Scholar]
  • 25.Williamson V, Greenberg N, Murphy D. Moral injury in UK armed forces veterans: a qualitative study. Eur J Psychotraumatol. 2019;10(1):1562842. 10.1080/20008198.2018.1562842. Medline:30693080 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Litz BT, Contractor AA, Rhodes C, et al. Distinct trauma types in military service members seeking treatment for posttraumatic stress disorder. J Trauma Stress. 2018;31(2):286–95. 10.1002/jts.22276. Medline:29669185 [DOI] [PubMed] [Google Scholar]
  • 27.Kelley ML, Bravo AJ, Davies RL, et al. Moral injury and suicidality among combat-wounded veterans: The moderating effects of social connectedness and self-compassion. Psychol Trauma. 2019;11(6):621–9. 10.1037/tra0000447. Medline:30896225 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Levi-Belz Y, Zerach G. Moral injury, suicide ideation, and behavior among combat veterans: the mediating roles of entrapment and depression. Psychiatry Res. 2018;269:508–16. 10.1016/j.psychres.2018.08.105. Medline:30195745 [DOI] [PubMed] [Google Scholar]
  • 29.Houtsma C, Khazem LR, Green BA, et al. Isolating effects of moral injury and low post-deployment support within the U.S. military. Psychiatry Research. 2017;247:194-99. 10.1016/j.psychres.2016.11.031. Medline:27918969 [DOI] [PubMed] [Google Scholar]
  • 30.Van Orden KA, Witte TK, Cukrowicz KC, et al. The interpersonal theory of suicide. Psychol Rev. 2010;117(2):575–600. 10.1037/a0018697. Medline:20438238 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Liu RT, Kleiman EM, Nestor BA, et al. The hopelessness theory of depression: a quarter-century in review. Clin Psychol. 2015;22(4):345–65. 10.1037/h0101732 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Fitzsimmons S, Craigie A, Bodet MA. Canadian public opinion about the military: assessing the influences on attitudes toward defence spending and participation in overseas combat operations. Can J Political Sci/Rev can sci politique. 2014;47(3):503–18. 10.1017/s0008423914000754 [DOI] [Google Scholar]
  • 33.Yakovleff M. The foundations of morale and ethics in the armed forces: some revealing variations among close allies. Inflexions. 2007;6(2):177–97. 10.3917/infle.006.0177 [DOI] [Google Scholar]
  • 34.National Defence. Joint suicide prevention strategy — Canadian Armed Forces and Veterans Affairs Canada [Internet]. Ottawa: Government of Canada; 2017. [cited 2018 August 29]. https://www.canada.ca/en/department-national-defence/corporate/reports-publications/caf-vac-joint-suicide-prevention-strategy.html [Google Scholar]
  • 35.Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59 Suppl 20:22–33; quiz 34-57. [PubMed] [Google Scholar]
  • 36.Kubany ES, Haynes SN, Abueg FR, et al. Development and validation of the Trauma-Related Guilt Inventory (TRGI). Psychol Assess. 1996;8(4):428–44. 10.1037/1040-3590.8.4.428 [DOI] [Google Scholar]
  • 37.Foa EB, Ehlers A, Clark DM, et al. The Posttraumatic Cognitions Inventory (PTCI): development and validation. Psychol Assess. 1999;11(3):303–14. 10.1037/1040-3590.11.3.303 [DOI] [Google Scholar]
  • 38.Weathers FW, Litz BT, Keane TM, et al. The PTSD Checklist for DSM-5 (PCL-5) [Internet]. Washington (DC): U.S. Department of Veterans Affairs; 2013. [cited 2017 Aug 2]. Available from: https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp. [Google Scholar]
  • 39.Steer RA, Ball R, Ranieri WF, et al. Further evidence for the construct validity of the Beck Depression Inventory-II with psychiatric outpatients. Psychol Rep. 1997;80(2):443–46. 10.2466/pr0.1997.80.2.443. Medline:9129364 [DOI] [PubMed] [Google Scholar]
  • 40.Nash WP, Carper TLM, Mills MA, et al. Psychometric evaluation of the Moral Injury Events Scale. Mil Med. 2013;178(6):646–52. 10.7205/milmed-d-13-00017. Medline:23756071 [DOI] [PubMed] [Google Scholar]
  • 41.Plouffe RA, Easterbrook B, Liu A, et al. Psychometric evaluation of the Moral Injury Events Scale in two Canadian Armed Forces samples. Assessment. 30(1):111–23 10.1177/10731911211044198 [DOI] [PubMed] [Google Scholar]
  • 42.King DW, King LA, Vogt DS. Manual for the Deployment Risk and Resilience Inventory (DRRI): a collection of measures for studying deployment-related experiences of military veterans. Boston: National Center for PTSD; 2003. [Google Scholar]
  • 43.Tangney J, Wagner P, Gramzow R. Proneness to shame, proneness to guilt, and psychopathology. J Abnorm Psychol. 1992;101(3):469–78. 10.1037/0021-843x.101.3.469. Medline:1500604 [DOI] [PubMed] [Google Scholar]
  • 44.Tangney JP, Stuewig J, Mashek DJ. Moral emotions and moral behavior. Annu Rev Psychol. 2007;58(1):345–72. 10.1146/annurev.psych.56.091103.070145. Medline:16953797 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Raps CS, Peterson C, Reinhard KE, et al. Attributional style among depressed patients. J Abnorm Psychol. 1982;91(2):102–8. 10.1037/0021-843x.91.2.102. Medline:7069047 [DOI] [PubMed] [Google Scholar]
  • 46.Rogers ML, Kelliher-Rabon J, Hagan CR, et al. Negative emotions in veterans relate to suicide risk through feelings of perceived burdensomeness and thwarted belongingness. J Affect Disord. 2017;208:15–21. 10.1016/j.jad.2016.09.038. Medline:27741431 [DOI] [PubMed] [Google Scholar]
  • 47.Deitz MF, Williams SL, Rife SC, et al. Examining cultural, social, and self-related aspects of stigma in relation to sexual assault and trauma symptoms. Violence Women. 2015;21(5):598–615. 10.1177/1077801215573330. Medline:25732041 [DOI] [PubMed] [Google Scholar]
  • 48.Sexton MB, Davis MT, Bennett DC, et al. A psychometric evaluation of the Posttraumatic Cognitions Inventory with Veterans seeking treatment following military trauma exposure. J Affect Disord. 2018;226:232–38. 10.1016/j.jad.2017.09.048. Medline:29017066 [DOI] [PubMed] [Google Scholar]
  • 49.Bryan CJ, Bryan AO, Anestis MD, et al. Measuring moral injury: psychometric properties of the Moral Injury Events Scale in two military samples. Assessment. 2016;23(5):557–70. 10.1177/1073191115590855. Medline:26092043 [DOI] [PubMed] [Google Scholar]
  • 50.Whiteman SE, Witte TK, Cero I, et al. Posttraumatic stress disorder and suicidal ideation: the moderating effect of posttraumatic cognitions. J Trauma Stress. 2021;34(6):1178–87. 10.1002/jts.22598. Medline:33025677 [DOI] [PubMed] [Google Scholar]
  • 51.Boska RL, Capron DW. Exploring the maladaptive cognitions of moral injury within a primarily combat-trauma military sample. Psychol Trauma. 2021;13(8):861–68. 10.1037/tra0001071. Medline:34435814 [DOI] [PubMed] [Google Scholar]
  • 52.Wilson LC. The prevalence of military sexual trauma: a meta-analysis. Trauma Violence Abuse. 2018;19(5): 584–97. 10.1177/1524838016683459. Medline:30415636 [DOI] [PubMed] [Google Scholar]
  • 53.Pellicane MJ, Ciesla JA. Associations between minority stress, depression, and suicidal ideation and attempts in transgender and gender diverse (TGD) individuals: systematic review and meta-analysis. Clin Psychol Rev. 2022;91:102113. 10.1016/j.cpr.2021.102113 [DOI] [PubMed] [Google Scholar]

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