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. Author manuscript; available in PMC: 2022 Jun 15.
Published in final edited form as: Psychol Trauma. 2020 Sep 7;13(4):403–411. doi: 10.1037/tra0000968

Examining the Relations Among Moral Foundations, Potentially Morally Injurious Events, and Posttraumatic Stress Disorder Symptoms

Shannon R Forkus 1, Nicole H Weiss 1
PMCID: PMC9199532  NIHMSID: NIHMS1791394  PMID: 32897089

Abstract

Military veterans are exposed to unique deployment stressors that can precipitate the onset of various psychological difficulties, including the perception that an important moral standard has been transgressed (i.e., potentially morally injurious events [PMIEs]) and the development of posttraumatic stress disorder (PTSD) symptoms. Vulnerability to these outcomes may be related to individual differences in moral foundations, including those that function to protect the individual (i.e., individualizing) and those that function to protect the group (i.e., binding).

Objective:

This study examined the direct and indirect associations among moral foundations, PMIEs, and PTSD symptoms.

Method:

Participants were 203 military veterans (M age = 35.08, 77.30% male) who completed an online survey.

Results:

Only the binding moral foundation was found to be significantly and positively associated with both PMIEs and PTSD symptoms. Further, the association between the binding foundation and PTSD symptoms was explained by PMIEs.

Conclusions:

These findings suggest that certain moral foundations, particularly those that serve “binding” functions—loyalty, authority, and purity—may be important considerations in military mental health.

Keywords: moral injury, moral foundations, posttraumatic stress disorder, military

The psychological effects of military deployment are significant, with an estimated 23% of veterans meeting diagnostic criteria for posttraumatic stress disorder (PTSD) following deployment (Fulton et al., 2015). PTSD is a debilitating mental health problem characterized by intrusions (e.g., nightmares, flashbacks), avoidance of internal (e.g., thoughts, emotions) and external (e.g., people, places, situations) trauma-related cues, negative alterations in cognition and mood (e.g., exaggerated self/other blame, difficulty experiencing positive affect), and alterations in arousal and reactivity (e.g., hypervigilance, exaggerated startle response) following traumatic exposure (American Psychiatric Association, 2013). PTSD is associated with a wide range of deleterious outcomes among military personnel (e.g., functional impairment, cooccurring problems; Monson, Taft, & Fredman, 2009; Seal et al., 2011; Stander, Thomsen, & Highfill-Mcroy, 2014). Recent findings indicate that risk for PTSD among military personnel may be pronounced among individuals that are exposed to events that are perceived as transgressing deeply held moral and ethical standards of behaviors; these events are known as potentially morally injurious events (PMIEs; Litz et al., 2009)

In the moral injury framework, an individual exposed to PMIEs may experience long-lasting psychological distress and functional impairment known as a moral injury (Litz et al., 2009). Specifically, moral injury may arise if attempts to cope with moral pain (normative reaction to morally inconsistent acts, e.g., shame, guilt; Farnsworth, Drescher, Evans, & Walser, 2017) are unsuccessful, leading to greater suffering across social, psychological, and spiritual domains. These moral injuries can manifest as a wide range of symptoms (Griffin et al., 2019; Wisco et al., 2017); more severe manifestations can resemble PTSD (Litz et al., 2018; Williamson, Stevelink, & Greenberg, 2018). For instance, committing or witnessing acts that involve the perceived transgression of an important moral standard may lead individuals to adopt problematic trauma-related appraisals related to perceived moral deficiencies or inherent flaws; they also may try to avoid internal and external reminders of the transgressive experience, and attempts to avoid event-related information may result in intrusive reminders of the event (e.g., nightmares, flashbacks), all of which resemble PTSD symptomology (American Psychiatric Association, 2013). Indeed, many studies found strong links between PMIEs and PTSD symptoms (for a review, see Williamson et al., 2018).

Although moral injury may manifest similarly to PTSD (Buechner & Jinkerson, 2016; Koenig, Youssef, Ames, Teng, & Hill, 2020), the symptoms may be functionally distinct. For instance, Farnsworth et al. (2017) described how PTSD-related avoidance may function to avoid perceived danger, whereas moral injury-related avoidance may function to avoid shame. Similarly, PTSD-related beliefs may be more descriptive in nature (i.e., the world is not a safe place), whereas moral injury-related beliefs may be more prescriptive (e.g., the world should be a safe place; Farnsworth, 2019). These distinctions highlight the importance of examining PTSD symptoms in relation to PMIEs. Research has begun to elucidate factors implicated in increasing risk for developing PTSD symptoms after experiencing an event that violates moral standards, such as self-blame, shame/guilt, and spiritual/religious struggles (Evans et al., 2018; Frankfurt, Frazier, & Engdahl, 2017; Held et al., 2017). Additional work is needed to identify factors involved in the association between PMIEs and PTSD symptoms to better inform clinical practice and theory.

Given the central role of personal moral standards in the moral injury framework, moral foundations may provide insight into individual differences in the perception of events as morally injurious and associated PTSD symptoms. The moral foundations theory (Haidt & Joseph, 2004) posits that moral systems are derived from five psychological foundations that have an evolutionary basis and serve an adaptive function. This framework extends morally relevant considerations beyond common conceptions of justice and care and includes moral ideals relating to loyalty, authority, and purity (Haidt, 2007; Haidt & Graham, 2007). The foundations are harm/care (sensitivity to violations of harm to others), fairness/reciprocity (sensitivity to unfair treatment and violations of rights), loyalty/in-group (sensitivity to violations of the group), authority/respect (sensitivity to violations of the social order, legitimate authority, and traditions), and purity/sanctity (sensitivity to violations of purity; Graham et al., 2013; Haidt & Graham, 2007). These foundations are believed to have developed to solve evolutionary problems at both the individual (i.e., protection of offspring) and group (i.e., protection of the tribe) level to help make social life possible (Graham, Haidt, & Nosek, 2009; Haidt, 2008). The harm/care and fairness/reciprocity foundations are considered the “individualizing foundations” as they are primarily concerned with the protection of individuals. The loyalty/in-group, authority/respect, and purity/sanctity foundations comprise the “binding foundations” as they are primarily concerned with the protection of the group (Graham et al., 2009; Haidt, 2008).

Moral foundations may be important to consider in regard to the moral injury framework. The moral injury framework is based on the premise that individuals have an internalized standard of morally acceptable behavior (Drescher et al., 2011; Litz et al., 2009), and acts that are deemed discrepant with this moral standard may generate an inner conflict. If unable to resolve this inner conflict by successfully integrating the events into preexisting self-schemata, moral injury can arise. The relation between these moral foundations and potentially moral injurious events can be understood through schema-based conceptions of morality, which suggest that individuals have various mental representations of what it means to be a moral person (i.e., moral prototype) and how to behave morally (i.e., moral scripts; Aquino & Reed, 2002; Lapsley & Narvaez, 2004). These moral ideals can become an integral part of how individuals choose to define their ideal self and an essential component of a person’s self-identity (Aquino & Reed, 2002; Blasi, 1983; Hardy & Carlo, 2005; Stets & Carter, 2006; Walker, 2004). Thus, behaviors that are inconsistent with these ideals would constitute a self-betrayal (Blasi, 1983). Because moral foundations may reflect a type of internalized moral ideal, events in the context of deployment that are incongruent with these moral foundations may be perceived as morally injurious.

Moral foundations—individualizing and binding—have yet to be examined in relation to PTSD symptoms; however, the conceptual relation can be derived from theories about the etiology and maintenance of PTSD symptomology. Theories suggests that events that violate global belief systems can lead to the formation of negative beliefs about oneself and the world, contributing to the development and maintenance of PTSD symptomology (Ehlers & Clark, 2000; Janoff-Bulman, 1992) as these events can be processed in a way that maintains a current sense of threat (Ehlers & Clark, 2000). Moral foundations reflect a belief system that aids in the determination of right and wrong and guides behavioral decisions to help individuals successfully navigate the world, and for veterans, these beliefs may help navigate challenging combat situations (e.g., morally ambiguous situations). When acts are deemed inconsistent with one’s moral foundations—that is, through the appraisal of events as morally injurious—the event may be processed in a way that compromises perceptions of safety, power/control, esteem, intimacy, and trust, all of which can contribute to the onset, maintenance, and/or severity of PTSD symptoms (Resick & Schnicke, 1992).

The majority of research on moral foundations has been used predominantly in literature pertaining to cultural and political ideological differences (e.g., Clifford, 2017; Milesi, 2016; Silver & Silver, 2017). To our knowledge, this is the first study to examine individualizing and binding moral foundations in the context of mental health and military populations. Considering the recent clinical and research attention on the moral complexities of combat, and associated mental health repercussions, moral foundations theory may provide a unique lens into the moral injury framework. Thus, the goal of the current study was to understand how the moral foundations (i.e., individualizing and binding) relate to PMIEs and PTSD symptoms. We expected significant and positive associations among moral foundations, PMIEs, and PTSD symptoms. Further, we expected that the relation between each moral foundation (individualizing and binding) and PTSD symptoms would be explained by exposure to PMIEs such that higher scores on moral foundations would relate to higher PMIEs scores, which in turn would result in greater PTSD symptom severity.

Method

Participants and Procedures

Data were collected as part of a larger study examining PMIEs and mental and behavioral health outcomes. Participants were recruited from Amazon’s Mechanical Turk (MTurk), an Internetbased crowdsourcing platform. MTurk has been shown to generate reliable data (Shapiro, Chandler, & Mueller, 2013) and closely represent the general population in terms of demographics (Mishra & Carleton, 2017) and prevalence of mental health problems (Shapiro et al., 2013), including PTSD (van Stolk-Cooke et al., 2018). The current study was advertised as a survey about military experiences and moral, emotional, and psychological well-being. The study was only advertised to MTurk workers who were located in the United States, indicated prior military service on demographic information, and had over a 95% approval rating. Interested participants were required to complete an initial screener to determine eligibility. In order to be eligible, participants had to (a) be at least 18 years old; (b) be living in North America; (c) have a working knowledge of the English language; (d) self-identify as a U.S. military veteran; (e) have served in support of Operations Iraqi Freedom, Enduring Freedom, or New Dawn; and (f) indicate at least one military deployment.

In addition to having participants self-identify as a military veteran, we also followed Lynn and Morgan’s (2016) recommendations to include a cautionary statement in the study advertisement that warned it was illegal to impersonate a veteran for financial gain. In addition to this, we included three military-specific validity questions to verify military status. These questions are not typically common knowledge to civilians (e.g., “What is the acronym for the locations where final physicals are taken prior to shipping off for basic training?”) and have been used in previous MTurk data collection (Lynn & Morgan, 2016). Participants who met these inclusionary criteria were then provided informed consent and completed the survey on an external data collection platform.

We also embedded three questions throughout the survey to assess attentive responding/comprehension (e.g., “Please select the color Red from the options given”), as is recommended for survey data collection to reduce careless responding (Meade & Craig, 2012). Participants who failed to correctly respond were excluded from the final sample. The average time to complete the survey was about 45 min. Participants were compensated $2.00 for their participation. These study procedures were approved by the institutional review board at the University of Rhode Island.

A total of 696 individuals accessed the survey. Of those, 431 were deemed ineligible for the study (n = 265) based on the above inclusion criteria, and 62 failed embedded validity checks (n = 203). The remaining sample included 203 Iraq and Afghanistan veterans. Ages ranged from 21 to 63, with a mean age of 35.08 (SD = 8.09). The majority of the sample were male (n = 157, 77.30%) and White (n = 143, 70.40%). Most of the sample reported serving in the Army (n = 106, 52.20%), followed by Air Force (n = 39, 19.20%), Navy (n = 32, 15.80%), and Marine Corps (n = 26, 12.80%), with the majority of the sample indicating that they were active duty (n = 173, 85.20%). See Table 1 for additional sample characteristics.

Table 1.

Sample Characteristics

Variables M(SD) n (%) PMIEs Individualizing Binding PTSD symptoms
Age 35.08 (8.09)
Gender
 Female 45(22.2) 29.02 (12.64) 40.89 (9.26) 52.76 (17.63) 29.89 (21.71)
 Male 157(77.3) 25.90 (12.65) 37.72 (10.67) 51.39 (17.20) 28.13 (22.53)
Race
 White 143(70.4) 25.65 (12.53) 38.01 (10.15) 50.51 (16.99) 26.08 (22.01)
 Black/African American 30(14.8) 26.07 (13.55) 40.23 (10.03) 55.30 (17.52) 26.87 (24.52)
 Asian 14(6.9) 29.85 (12.13) 38.23 (12.94) 54.69 (19.05) 38.92 (17.59)
 American Indian 11(5.4) 36.09 (7.44) 41.82 (8.49) 54.55 (17.34) 46.27 (11.94)
Ethnicity
 Hispanic or Latino 28(13.8) 25.00 (13.11) 35.58 (8.91) 50.23 (12.77) 27.50 (22.75)
 Not Hispanic or Latino 168(82.8) 26.74 (12.42) 38.85 (10.46) 51.64 (17.83) 28.18 (22.21)
Military service
 Army 106(52.2) 29.52 (12.18) 38.12 (10.41) 53.04 (16.80) 32.44 (23.66)
 Marines 26(12.8) 26.92 (11.47) 36.73 (9.72) 52.31 (17.56) 33.58 (20.94)
 Air Force 39(19.2) 21.97 (12.10) 40.54 (10.24) 49.49 (17.28) 20.54 (17.95)
 Navy 32(15.8) 23.00 (13.27) 39.04 (9.93) 50.07 (17.99) 21.71 (21.09)
Status
 Active 173(85.2) 26.31 (12.26) 38.58 (10.24) 50.62 (17.09) 28.59 (22.02)
 Reserve 16(7.9) 27.43 (11.90) 38.43 (10.32) 58.86 (14.57) 23.14 (20.80)
 Guard 14(6.9) 31.07 (16.60) 38.29 (10.21) 59.00 (17.21) 35.21 (28.59)
Number of deployments
 1 69(34.0) 25.03 (13.14) 39.37 (9.55) 51.64 (15.79) 28.10 (24.38)
 2 67(33.0%) 29.42 (11.84) 37.58 (10.98) 50.68 (18.20) 32.23 (21.90)
 3 36(17.7) 26.18 (11.76) 38.00 (9.53) 55.09 (15.92) 25.67 (20.59)
 4 or more 31(15.3) 25.30 (13.29) 39.40 (10.88) 51.03 (19.05) 25.53 (21.05)
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Note. PMIEs = potentially morally injurious events; PTSD = posttraumatic stress disorder.

Measures

PMIEs.

The Moral Injury Events Scale (Nash et al., 2013) is a nine-item self-report scale measuring exposure to PMIEs, including perceived transgressions committed by self (four items; e.g., “I am troubled by having acted in ways that violated my own morals or values”) or others (two items; e.g., “I am troubled by having witnessed others’ immoral acts”) and perceived betrayal (three items; e.g., “I feel betrayed by fellow service members who I once trusted”). Responses are given on a 6-point Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree). A total score was computed by summing all items. This scale has demonstrated excellent psychometric properties (Bryan et al., 2016; Nash et al., 2013), including good internal consistency in this current sample (α = 93).

Moral foundations.

The Moral Foundations Questionnaire (Graham et al., 2011) is a 30-item self-report scale that measures an individual’s endorsement of five different types of moral foundations: harm/care, fairness/reciprocity, loyalty/in-group, authority/respect, and purity/sanctity. For the first 15 items, participants are asked to rate on a scale from 0 (not at all relevant) to 5 (extremely relevant) how relevant each of 15 concerns are to them when making moral judgments (e.g., “Whether or not some people were treated differently from others”). For the second 15 items, participants are then asked to rate their level of agreement with statements that reflect each of the different foundations (e.g., “Compassion for those who are suffering is the most crucial virtue”) on a scale from 0 (strongly disagree) to 5 (strongly agree). Total scores were computed by summing the items on each respective scale to create an individualizing (harm/care, fairness/ reciprocity) and binding (loyalty/in-group, authority/respect, and purity/sanctity) sum score (consistent with previous studies; Barnett, Öz, & Marsden, 2018). The scale has been shown to be a reliable and valid measure (Graham et al., 2011). Internal consistency for these moral foundation subscales was excellent: individualizing (α =.84) and binding (α =.91).

PTSD symptoms.

The PTSD Checklist (PCL-5; Weathers et al., 2013) is a 20-item self-report assessment used to assess pastmonth PTSD symptoms consistent with the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2013). Participants were asked to indicate how often they have been bothered by each of the symptoms over the past month in reference to their most stressful deployment-related experience. Each response is given on a 5-point Likert scale ranging from 0 (not at all) to 4 (extremely). A score was calculated by summing all the items. Higher scores indicated greater PTSD symptom severity. The PCL-5 has been shown to have excellent psychometric properties (Blevins, Weathers, Davis, Witte, & Domino, 2015). Internal consistency of the PCL-5 in the current study was also excellent (α =.97).

Data Analysis

Preliminary analyses were first conducted to obtain descriptive information and examine intercorrelations among the primary study variables (see Table 2). Data were analyzed using SPSS v.24 statistical software.

Table 2.

Intercorrelations Among the Primary Study Variables

Study variables 1 2 3 4 M (SD)
1. Individualizing moral foundation — — — — 38.38 (10.44)
2. Binding moral foundation .42** — — — 51.59 (17.29)
3. PMIEs .12 .24* — — 26.58 (12.66)
4. PTSD symptoms .04 .21* .64** — 28.47 (22.27)
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Note. PMIEs = potentially morally injurious events; PTSD = posttraumatic stress disorder.

*

p < .01.

**

p < .001.

Mediation analyses were then conducted to examine the direct and indirect associations among moral foundations (binding and individualizing, separately), PMIEs, and PTSD symptoms (see Figure 1). These analyses were conducted using the PROCESS macro for SPSS (Model 4). PROCESS uses ordinary least squares regression and bootstrapping procedures (Preacher & Hayes, 2004). Bootstrapping was done with 5,000 random samples generated from the observed covariance matrix to estimate 95% confidence intervals and significance values. The indirect effect is considered significant if the upper and lower bounds of the 95% confidence interval do not contain zero (Preacher & Hayes, 2004).

Figure 1.

Figure 1.

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Mediational analyses. In the primary analyses, the a paths represent the associations between the predictor (moral foundation type) and the mediator (potentially morally injurious events [PMIEs]). The b paths represent the associations between the mediator variable and the outcome (posttraumatic stress disorder [PTSD] symptoms). The c paths represent the direct association between and predictor and the outcome, and the c’ paths represent the direct path from the predictor to the outcome, while controlling for the indirect paths in the model. The indirect effects are the product of paths a and b. * represents significant at the <.001 level.

Results

Descriptive information and intercorrelations among the primary study variables were examined. Specifically, Pearson correlations among PMIEs, the individualizing and binding moral foundations, and PTSD symptoms are presented in Table 2. The binding, but not individualizing, moral foundation was significantly and positively associated with PMIEs and PTSD symptoms. Further, positive and significant associations were found between the individualizing and binding moral foundations, as well as PMIEs and PTSD symptoms.

See Table 3 for unstandardized estimates, standard errors, t scores, and p values. Mediation analyses were conducted to examine the direct and indirect associations among primary variables. In Model 1, the binding foundation was significantly associated with PMIEs (a path; b =.17, SE = .05, t = 3.41, p < .001), and PMIEs were significantly associated with PTSD symptoms (b path; b = 1.10, SE = .10, t = 11.09, p < .001); the direct association linking the binding foundation to PTSD symptoms was also significant (c path; b = .25, SE = .09, t = 2.78, p = .006). Further, the indirect association was significant (b = .19, SE = .06, 95% CI [.08, .31]), and the direct association (c’ path; b = .06, SE = .07, t = .83, p = .41) was no longer significant after controlling for the indirect relations in the model.

Table 3.

Summary of Mediational Analyses

Paths B SE t p
Model 1
 Binding → PMIEs (a) 0.17 0.05 3.41 <.001
 PMIEs → PTSD symptoms (b) 1.10 0.10 11.09 <.001
 Binding → PTSD symptoms (c’) 0.06 0.07 0.83 .41
Model 2
 Individualizing → PMIEs (a) 0.15 0.09 1.70 .09
 PMIEs → PTSD symptoms (b) 1.17 0.10 11.88 <.001
 Individualizing → PTSD symptoms (c’) −0.14 0.12 −1.16 .25
Indirect paths B SE BootLLCI BootULCI
Model 1 PMIEs (a × b) 0.19 0.06 0.08 0.31
Model 2 PMIEs (a × b) 0.18 0.11 −0.03 0.38
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Note. SE = standard error; PMIEs = potentially morally injurious events; PTSD = posttraumatic stress disorder; BootLLCI = bootstrapped 95% confidence interval lower limit; BootULCI = bootstrapped 95% confidence interval upper limit.

In Model 2, the individualizing foundation was not significantly associated with PMIEs (a path; b = .15, SE = .09, t = 1.70, p = .09); however, PMIEs were significantly associated with PTSD symptoms (b path; b = 1.17, SE = .10, t = 11.88, p < .001). The direct association linking the individualizing foundation with PTSD symptoms was not significant (c path; b = .03, SE = .16, t = .33, p = .74). Further, the indirect association was not significant (b = .18, SE = .11, 95% CI [−.03, .38]), and the direct association (c’ path; b = −.14, SE = .12, t = −1.16, p = .25) remained nonsignificant after controlling for the indirect relations in the model.

Discussion

Theoretically, negative mental health symptoms can arise when moral beliefs are contradicted (Litz et al., 2009), and empirically, PMIEs have been found to relate to PTSD symptoms (Williamson et al., 2018). Thus, the goal of this study was to examine a specific type of moral belief system—that is, individualizing and binding moral foundations—in relation to both PMIEs and PTSD symptoms. The binding foundation was found to be directly linked to both PMIEs and PTSD symptoms, and PMIEs mediated the relation between the binding foundation and PTSD symptoms. These findings provide preliminary insight into the role of moral foundations in military mental health. Findings may have important implications for future research and clinical practice.

The results showed significant positive associations between the binding foundation and PMIEs and PTSD symptoms only; no significant associations were found between the individualizing foundation and these constructs. Findings may suggest that those whose beliefs center around being loyal and pure (vs. being caring and fair) may be especially vulnerable to moral injuries in a military context; specifically, they may be more attentive to how their actions, and the actions of others, violate military traditions and ethos that reflect ideals that serve this binding function. This finding stands in contrast to previous assertions suggesting that moral injury largely stems from violations of harm-based conceptions of morality: Witnessing a fellow service member harm a noncombatant may produce stress related not only to harm but also to violations of loyalty, authority, or purity. In a combat setting, violations of the binding foundation may seem particularly severe as it reflects a collective moral standard; therefore, transgressing this standard may be perceived as having larger implications (i.e., jeopardizing the mission or fellow service member’s safety).

These associations were further explored by examining the mediating role of PMIEs on the association between moral foundations and PTSD symptoms. Findings revealed that PMIEs only explained the association between the binding foundation and PTSD symptoms. Although inconsistent with expectations, the nonsignificant finding regarding the individualizing foundation may suggest that these types of moral beliefs may not be as prioritized in military contexts. For instance, it may be less useful for veterans to prioritize beliefs centered on minimizing harm and promoting fairness in certain military settings as they may have had less adaptive value, whereas threats to binding foundations may be perceived as more negative or dangerous. Further, there are certain military values and behaviors that seem to highlight the relevance of the individualizing foundation by emphasizing the protection of an individual (e.g., leave no soldier behind); however, these values may actually reflect the binding foundation by emphasizing the importance of loyalty. Thus, in this context, individualizing-type beliefs may fall under the binding foundation, functioning to protect the group.

The role of the binding foundation in relation to PMIEs and PTSD symptoms may be due to certain contextual features of the military. The military is an institution that emphasizes certain ethos, values, and codes that are grounded in traditions that resemble the binding foundation (e.g., warrior ethos, soldiers’ creed), and these cultural facets can become internalized as they are commonly reinforced in the military environment (Riccio, Sullivan, Klein, Salter, & Kinnison, 2004). For instance, the warrior ethos is instilled during military training and service and becomes a standard for how soldiers are expected to operate during military service, and for some, it can become a permanent and central part of their self-identity. The ethos emphasizes placing the mission first and never accepting defeat, quitting, or leaving a fallen comrade (Riccio et al., 2004).

The assimilation of these principles into one’s own belief system reflects a shared understanding that serving the nation is an honor and responsibility that is larger than oneself and that the needs of the individual should come secondary to the mission. Further, adherence to these aspects of the military are believed to be the backbone of the organization of the military as they are essential for maximizing the efficacy of the mission, which often has greater, global implications. In addition, identification with the military, and internalization of these codes, can minimize individual differences and reorient individuals to a more collective or integrated military identity (Redmond et al., 2015). Further, in the context of the military, these beliefs may serve an adaptive purpose by maximizing survival and the success of the mission. Violation of these potentially protective beliefs may compromise perceptions of safety, trust, power/control, and esteem. For instance, individuals exposed to trauma can develop negative, overgeneralized beliefs related to self, others, and the world (e.g., no one can be trusted), and these beliefs can increase perceptions of vulnerability contributing to the onset and severity of PTSD symptoms (Resick, Monson, & Chard, 2007).

Clinical Implications

To our knowledge, this is the first study to examine associations among individualizing and binding moral foundations, PMIEs, and PTSD symptoms. Results of the current study support the theoretical role of moral beliefs in relation to the moral injury framework (Litz et al., 2009). Our findings extend this understanding to incorporate the role of specific moral foundations and the ways in which certain sensitivities to various moral foundations may be related to PMIEs and PTSD symptoms. Our findings highlight the need for additional research aimed at clarifying the role of moral foundations in the development, maintenance, and exacerbation of PTSD symptoms. Investigations in this area may inform strategies to improve treatments for veterans. For instance, someone who is experiencing negative thoughts relating to a perceived failure to uphold their moral foundation may benefit from cognitive processing therapy (CPT). CPT is commonly used to address PTSD in veterans (Monson et al., 2006) and has been recommended for treating moral injury (Wachen et al., 2016). The goal of CPT is to challenge maladaptive cognitions to develop a more balanced and realistic set of beliefs (Resick et al., 2007). Thus, CPT could be used to challenge maladaptive thoughts or compromised perceptions of trust, power/control, safety, and esteem that may arise when there is a perceived failure to act in accordance with one’s moral system. Importantly, we do not suggest that clinical interventions should seek to challenge or change moral foundations themselves, but rather that they should target the specific types of negative beliefs that may arise when these foundations are threatened. Interventions that are aligned with and validate existing moral foundations may in fact be more effective than those that encourage a different moral framework.

Limitations and Future Directions

Although the present study contributes to the literature on moral injury, moral foundations, and mental health, there are several limitations worthy of consideration. First, the use of cross-sectional data limits the ability to assess the true direction of these relations. Specifically, we are unable to determine participants’ moral foundations at the time of the traumatic exposure or if their beliefs have changed since the event. Future research should examine these relations using a longitudinal framework to examine moral foundations over time and to examine the temporal relationship of moral foundations, PMIEs, and PTSD symptoms. Second, the reliance on self-report data means that responses may be influenced by an individual’s willingness and ability to accurately respond. Future work should incorporate multiple methods of assessment, such as behavioral or physiological assessments. Third, the sample was collected using MTurk, which limits generalizability to those that have access to the Internet. Therefore, replication of these findings is needed in larger and more diverse military samples (e.g., treatment-seeking military samples). Fourth, the MTurk platform requires individuals to self-select to participate; as a result, there may be systematic differences between those who did (vs. did not) elect to participate. Results will need to be replicated using alternative recruitment strategies. Fifth, to our knowledge, the moral foundations questionnaire has yet to be validated in a military sample. Future research is needed to examine the factor analytic structure and construct validity among military personnel and veterans. Sixth, given our sample size, we did not have sufficient power to covary for other variables; however, considering that moral foundations relate to ideological differences, various demographic characteristics (i.e., gender, geographic region, religion/spiritual background) would be valuable to examine in these associations. Future studies should examine these relations with a large sample size to examine whether the findings hold while controlling for relevant demographic and military characteristics. Seventh, PTSD symptoms were assessed in relation to participants’ most distressing deployment-related experience, and we therefore do not know if these stressful experiences necessarily met Criterion A trauma. Future research should examine the nature of the deployment-related experiences to examine how different deployment-related stressors differentially relate to PTSD symptoms. Last, we used mediation analyses to examine the indirect and direct associations among moral foundations, PMIEs, and PTSD symptoms; however, given the cross-sectional nature of our data, we are not suggesting directionality. Instead, our findings are emphasizing correlational and cross-sectional associations among these constructs. Furthermore, these findings highlight the importance of examining these relations using longitudinal frameworks to elucidate temporal relations.

While our findings seem to suggest that the prioritization of the binding foundations are associated with more negative outcomes, they also may be protective in this context (e.g., may facilitate assimilation into military culture, promote unit cohesion). More research is needed to better examine these relations. Furthermore, it is important to note that individualizing foundations may be related to negative outcomes in other contexts (or even other unmeasured outcomes in this context); additional research is needed to better understand these moral foundations in relation to military mental health outcomes.

Conclusion

Despite limitations, results of the present study extend the body of research on military mental health. Moral foundations—that is, binding foundations—were found to relate to PMIEs and PTSD symptoms. Results underscore the importance of considering different types of moral beliefs in relation to mental health. Moreover, these results have important clinical implications. Specifically, our results suggest that moral foundations may be useful in predicting risk for developing PTSD symptoms. Further, if replicated, our findings indicate that it may be beneficial for military personnel and clinicians to assess moral foundations when assessing for moral injury, to better tailor treatments, and potentially mitigate the formation of severe or persistent psychological conditions. An avenue for future research would be to explore relative changes in moral foundations following exposure to combat and following treatment interventions. Overall, our findings provide preliminary support for the role of moral foundations in military mental health; however, more research is needed to replicate and extend our findings.

Clinical Impact Statement.

Military veterans are at heightened risk for experiencing events that are perceived as transgressing an important moral standard (i.e., potentially morally injurious events [PMIEs]) and developing posttraumatic stress disorder (PTSD). Thus, examining factors that relate to both PMIEs and PTSD is important for informing theory and practice. Different types of moral belief systems—one that focuses on the protection of the individual (i.e., individualizing) and one that emphasizes the protection of the group (i.e., binding)—were examined in relation to PMIEs and PTSD symptoms. Findings revealed that only the binding foundation was significantly related to PTSD symptoms, and when PMIEs were included in this relation, the association no longer remained. These results seem to suggest that PMIEs account for the relation between the binding foundation and PTSD symptoms. Findings provide novel information on the associations among moral foundations, PMIEs, and PTSD symptoms, which can be used to inform theoretical frameworks and clinical interventions.

Acknowledgments

Work on this study by Nicole H. Weiss was supported in part by National Institute on Drug Abuse Grant K23DA039327. We have no known conflict of interest to disclose.

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