The Role of Moral Injury in the Relationship Between Intimate Partner Violence and Psychological Distress

Abstract

Intimate partner violence (IPV) is consistently associated with deleterious mental health outcomes. Moral injury, a distinct form of trauma that can arise from witnessing, engaging in, failing to prevent, or being the victim of acts that conflict with one’s moral beliefs, is similarly associated with adverse mental health. However, despite the conceptual relation between moral injury and IPV, no previous research to these authors’ knowledge has examined this relationship. The present study investigated IPV experiences (perpetration and victimization), moral injury, and psychological distress in a sample of diverse college students (N = 152). We hypothesized that IPV experiences would be positively associated with moral injury and psychological distress, that moral injury would be positively associated with psychological distress, and that moral injury would mediate the relationship between IPV experiences and psychological distress. Results revealed significant positive correlations between IPV experiences, moral injury, and psychological distress. Mediation analyses revealed that both self-directed and other-directed moral injury fully mediated the relationship between IPV perpetration and psychological distress, while only self-directed moral injury emerged as a significant mediator between IPV victimization and psychological distress. These findings highlight the complex relationships among IPV, moral injury, and psychological distress, and underscore the importance of assessing moral injury in IPV-affected individuals. The present study addresses gaps in the literature by examining moral injury in a diverse, civilian sample of IPV survivors and perpetrators.

Keywords

intimate partner violence/abuse mental health effects offenders/perpetrators trauma mental health and violence

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References

Akça

Gençöz

(2021). The experience of disgust in women exposed to domestic violence in Turkey. Journal of Interpersonal Violence, 37(15–16), NP14538–NP14563. https://doi.org/10.1177/08862605211013953

Babcock

R. L.

DePrince

A. P.

(2012). Childhood betrayal trauma and self-blame appraisals among survivors of intimate partner abuse. Journal of Trauma & Dissociation, 13(5), 526–538. https://doi.org/10.1080/15299732.2012.694842

Barnes

H. A.

Hurley

R. A.

Taber

K. H.

(2019). Moral injury and PTSD: Often co-occurring yet mechanistically different. The Journal of Neuropsychiatry and Clinical Neurosciences, 31(2), A4–A103. https://doi.org/10.1176/appi.neuropsych.19020036

Basile

K. C.

Smith

S. G.

Wang

Friar

(2022). Characteristics and impacts of sexual violence and stalking victimization by the same perpetrator using a nationally representative sample. Journal of Aggression, Maltreatment & Trauma, 32(9), 1–14. https://doi.org/10.1080/10926771.2022.2133660

Beck

J. G.

McNiff

Clapp

J. D.

Olsen

S. A.

Avery

M. L.

Hagewood

J. H.

(2011). Exploring negative emotion in women experiencing intimate partner violence: Shame, guilt, and PTSD. Behavior Therapy, 42(4), 740–750. https://doi.org/10.1016/j.beth.2011.04.001

Cafferky

B. M.

Mendez

Anderson

J. R.

Stith

S. M.

(2018). Substance use and intimate partner violence: A meta-analytic review. Psychology of Violence, 8(1), 110–131. https://doi.org/10.1037/vio0000074

Čartolovni

Stolt

Scott

P. A.

Suhonen

(2021). Moral injury in healthcare professionals: A scoping review and discussion. Nursing Ethics, 28(5), 590–602. https://doi.org/10.1177/0969733020966776

Currier

J. M.

Farnsworth

J. K.

Drescher

K. D.

McDermott

R. C.

Sims

B. M.

Albright

D. L.

(2018). Development and evaluation of the Expressions of Moral Injury Scale-Military Version. Clinical Psychology & Psychotherapy, 25(3), 474–488. https://doi.org/10.1002/cpp.2170

Currier

J. M.

Smith

P. N.

Kuhlman

(2017). Assessing the unique role of religious coping in suicidal behavior among U.S. Iraq and Afghanistan veterans. Psychology of Religion and Spirituality, 9(1), 118–123. https://doi.org/10.1037/rel0000055

10.

Dadario

N. B.

Sughrue

M. E.

(2023). The functional role of the precuneus. Brain, 146, 3598–3607. https://doi.org/10.1093/brain/awad181

11.

Dodson

T. S.

Beck

J. G.

(2017). Posttraumatic stress disorder symptoms and attitudes about social support: Does shame matter? Journal of Anxiety Disorders, 17, 106–113. https://doi.org/10.1016/j.janxdis.2017.01.005

12.

Fani

Currier

J. M.

Turner

M. D.

Guelfo

Kloess

Jain

Mekawi

Kuzyk

Hinrichs

Bradley

Powers

Stevens

J. S.

Michopoulos

Turner

J. A.

(2021). Moral injury in civilians: associations with trauma exposure, PTSD, and suicide behavior. European Journal of Psychotraumatology, 12(1), 1965464. https://doi.org/10.1080/20008198.2021.1965464

13.

Fleming

W. H.

(2022). Complex moral injury: Shattered moral assumptions. Journal of Religion and Health, 61(2), 1022–1050. https://doi.org/10.1007/s10943-022-01542-4

14.

Ford-Gilboe

Varcoe

Wuest

Campbell

Pajot

Heslop

Perrin

(2022). Trajectories of depression, post-traumatic Stress, and chronic pain among women who have separated from an abusive partner: A Longitudinal Analysis. Journal of Interpersonal Violence, 38(1–2), NP1540–NP1568. https://doi.org/10.1177/08862605221090595

15.

Godfrey

D. A.

Kehoe

C. M.

Bennett

V. E.

Pollard

D. L.

Babcock

J. C.

(2023). Examining the associations between multi-dimensional facets of emotional abuse and posttraumatic stress disorder among trauma exposed women. Journal of Family Violence, 38(4), 1431–1441. https://doi.org/10.1007/s10896-022-00429-y

16.

Griffin

B. J.

Purcell

Burkman

Litz

B. T.

Bryan

C. J.

Schmitz

Villierme

Walsh

Maguen

(2019). Moral injury: An integrative review. Journal of Traumatic Stress, 32(3), 350–362. https://doi.org/10.1002/jts.22362

17.

Hacıaliefendioğlu

A. M.

Yılmaz

Smith

Whiting

Koyutürk

Karakurt

(2021). Data-driven identification of subtypes of intimate partner violence. Scientific Reports, 11(1), 6736. https://doi.org/10.1038/s41598-021-85947-3

18.

Hall

N. A.

Everson

A. T.

Billingsley

M. R.

Miller

M. B.

(2021). Moral injury, mental health and behavioural health outcomes: A systematic review of the literature. Clinical Psychology & Psychotherapy, 29(1), 92–110. https://doi.org/10.1002/cpp.2607

19.

Harper

F. W. K.

Austin

A. G.

Cercone

J. J.

Arias

(2005). The role of shame, anger, and affect regulation in men’s perpetration of psychological abuse in dating relationships. Journal of Interpersonal Violence, 20(12), 1648–1662. https://doi.org/10.1177/0886260505278717

20.

Hayes

A. F.

(2013). Introduction to mediation, moderation, and conditional process analysis. Guilford Press.

21.

Hegarty

Lamb

Stevelink

S. A. M.

Bhundia

Raine

Doherty

M. J.

Scott

H. R.

Marie Rafferty

Williamson

Dorrington

Hotopf

Razavi

Greenberg

Wessely

(2022). “It hurts your heart”: frontline healthcare worker experiences of moral injury during the COVID-19 pandemic. European Journal of Psychotraumatology, 13(2), 2128028. https://doi.org/10.1080/20008066.2022.2128028

22.

Held

Klassen

B. J.

Hall

J. M.

Friese

T. R.

Bertsch-Gout

M. M.

Zalta

A. K.

Pollack

M. H.

(2019). “I knew it was wrong the moment I got the order”: A narrative thematic analysis of moral injury in combat veterans. Psychological Trauma, 11(4), 396–405. https://doi.org/10.1037/tra0000364

23.

Hundt

N. E.

Holohan

D. R.

(2012). The role of shame in distinguishing perpetrators of intimate partner violence in U.S. veterans. Journal of Traumatic Stress, 25(2), 191–197. https://doi.org/10.1002/jts.21688

24.

Ivany

Schminkey

(2016). Intimate partner violence and traumatic brain injury: State of the science and next steps. Family and Community Health, 39(2), 129–137. https://doi.org/10.1097/FCH.0000000000000094

25.

Iverson

K. M.

Dardis

C. M.

Grillo

A. R.

Galovski

T. E.

Pogoda

T. K.

(2019). Associations between traumatic brain injury from intimate partner violence and future psychosocial health risks in women. Comprehensive Psychiatry, 92, 13–21. https://doi.org/10.1016/j.comppsych.2019.05.001

26.

Jamieson

Carey

L. B.

Jamieson

Maple

(2023). Examining the association between moral injury and suicidal behavior in military populations: A systematic review. Journal of Religion & Health, 62, 3904–3925. https://doi.org/10.1007/s10943-023-01885-6

27.

Jinkerson

J. D.

(2016). Defining and assessing moral injury: A syndrome perspective. Traumatology, 22(2), 122–130. https://doi.org/10.1037/trm0000069

28.

Johnson

W. L.

Giordano

P. C.

Longmore

M. A.

Manning

W. D.

(2014). Intimate partner violence and depressive symptoms during adolescence and young adulthood. Journal of Health and Social Behavior, 55(1), 39–55. https://doi.org/10.1177/0022146513520430

29.

Kennedy

A. C.

Prock

K. A.

(2018). “I still feel like I am not normal”: A review of the role of stigma and stigmatization among female survivors of child sexual abuse, sexual assault, and intimate partner violence. Trauma, Violence, & Abuse, 19(5), 512–527. https://doi.org/10.1177/1524838016673601

30.

Lathan

E. C.

Powers

Kottakis

Guelfo

Siegle

G. J.

Turner

J. A.

Turner

M. D.

Yakkanti

Jain

Mekawi

Teer

A. P.

Currier

J. M.

Fani

(2022). Civilian moral injury: Associations with trauma type and high-frequency heart rate variability in two trauma-exposed community-based samples. Psychological Medicine, 53, 1–10. https://doi.org/10.1017/s003329172200215x

31.

Levi-Belz

Groweiss

Blank

(2023). Moral injury and its mental health consequences among protesters: findings from Israel’s civil protest against the government’s judicial reform. European Journal of Psychotraumatology, 14(2), 2283306. https://doi.org/10.1080/20008066.2023.2283306

32.

Litz

B. T.

Lebowitz

Gray

M. J.

Nash

W. P.

(2016). Adaptive disclosure: A new treatment for military trauma, loss, and moral injury. The Guilford Press.

33.

Litz

B. T.

Plouffe

R. A.

Nazarov

Murphy

Phelps

Coady

Houle

S. A.

Dell

Frankfurt

Zerach

Levi-Belz

(2022). Defining and assessing the syndrome of moral injury: Initial findings of the moral injury outcome scale consortium. Frontiers in Psychiatry, 13, 923928. https://doi.org/10.3389/fpsyt.2022.923928

34.

Litz

B. T.

Stein

Delaney

Lebowitz

Nash

W. P.

Silva

Maguen

(2009). Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695–706. https://doi.org/10.1016/j.cpr.2009.07.003

35.

Lovibond

S. H.

Lovibond

P. F.

(1995). Depression Anxiety Stress Scales (DASS-21, DASS-42). APA PsycTests.

36.

Maguen

Griffin

B. J.

Copeland

L. A.

Perkins

D. F.

Finley

E. P.

Vogt

(2020). Gender differences in prevalence and outcomes of exposure to potentially morally injurious events among post-9/11 veterans. Journal of Psychiatric Research, 130, 91–103. https://doi.org/10.1016/j.jpsychires.2020.06.020

37.

McDaniel

J. T.

Redner

Jayawardene

Haun

Clapp

Che

Renzaglia

Abou-Jabal

(2023). Moral Injury is a risk factor for substance use and suicidality among US military veterans with and without traumatic brain injury. Journal of Religion & Health, 62(6), 3926–3941. https://doi.org/10.1007/s10943-023-01905-5

38.

McLaughlin

O’Carroll

R. E.

O’Connor

R. C.

(2012). Intimate partner abuse and suicidality: A systematic review. Clinical Psychology Review, 32(8), 677–689. https://doi.org/10.1016/j.cpr.2012.08.002

39.

Morland

L. A.

Leskin

G. A.

Block

C. R.

Campbell

J. C.

Friedman

M. J.

(2008). Intimate partner violence and miscarriage: Examination of the role of physical and psychological abuse and posttraumatic stress disorder. Journal of Interpersonal Violence, 23(5), 652–669.

40.

Naismith

Ripoll-Nuñez

Baquero Henao

(2024). Depression, anxiety, and post traumatic stress disorder following intimate partner violence: The role of self-criticism, guilt, and gender beliefs. Violence Against Women, 30(3–4), 791–811. https://doi.org/10.1177/10778012221142917

41.

Nam

Maxwell

S. R.

(2020). Assessing the effects of witnessed parental conflict and guilt on dating violence perpetration among South Korean college students. Journal of Family Violence, 36(3), 293–305. https://doi.org/10.1007/s10896-020-00155-3

42.

Nash

W. P.

Marino Carper

T. L.

Mills

M. A.

Goldsmith

Litz

B. T.

(2013). Psychometric evaluation of the Moral Injury Events Scale. Military Medicine, 178(6), 646–652. https://doi.org/10.7205/milmed-d-13-00017

43.

Neria

Pickover

(2019). Commentary on the Special Issue on Moral Injury: Advances, gaps in literature, and future directions. Journal of Traumatic Stress, 32(3), 459–464. https://doi.org/10.1002/jts.22402

44.

Norman

S. B.

Nichter

Maguen

P. J.

Schnurr

P. P.

Pietrzak

R. H.

(2022). Moral injury among U.S. combat veterans with and without PTSD and depression. Journal of Psychiatric Research, 154, 190–197.

45.

Platt

M. G.

Freyd

J. J.

(2015). Betray my trust, shame on me: Shame, dissociation, fear, and betrayal trauma. Psychological Trauma, 7(4), 398–404. https://doi.org/10.1037/tra0000022

46.

Roth

S. L.

Andrews

Protopopescu

Lloyd

O’Connor

Losier

B. J.

Lanius

R. A.

McKinnon

M. C.

(2022). Mental health symptoms in Public Safety Personnel: Examining the effects of adverse childhood experiences and moral injury. Child Abuse & Neglect, 123, 105394. https://doi.org/10.1016/j.chiabu.2021.105394F

47.

Schorr

Stein

N. R.

Maguen

Barnes

J. B.

Bosch

Litz

B. T.

(2018). Sources of moral injury among war veterans: A qualitative evaluation. Journal of Clinical Psychology, 74(12), 2203–2218. https://doi.org/10.1002/jclp.22660

48.

Scott-Storey

O’Donnell

Ford-Gilboe

Varcoe

Wathen

Malcolm

Vincent

(2022). What about the men? A critical review of men’s experiences of intimate partner violence. Trauma, Violence, & Abuse, 24(2), 858–872. https://doi.org/10.1177/15248380211043827

49.

Shay

(1994). Achilles in Vietnam: Combat trauma and the undoing of character. Scribner.

50.

Šimić

Tkalčić

Vukić

Mulc

Španić

Šagud

Olucha-Bordonau

F. E.

Vukšić

Hof

P. R.

(2021). Understanding emotions: Origins and roles of the amygdala. Biomolecules, 11(6), 823. https://doi.org/10.3390/biom11060823

51.

Sippel

L. M.

Marshall

A. D.

(2011). Posttraumatic stress disorder symptoms, intimate partner violence perpetration, and the mediating role of shame processing bias. Journal of Anxiety Disorders, 25(7), 903–910. https://doi.org/10.1016/j.janxdis.2011.05.002

52.

Spencer

Mallory

A. B.

Cafferky

B. M.

Kimmes

J. G.

Beck

A. R.

Stith

S. M.

(2019). Mental health factors and intimate partner violence perpetration and victimization: A meta-analysis. Psychology of Violence, 9(1), 1–17. https://doi.org/10.1037/vio0000156

53.

Straus

M. A.

Hamby

S. L.

Boney-McCory

Sugarman

D. B.

(1996). The Revised Conflict Tactics Scales (CTS2). Journal of Family Issues, 17(3), 283–316. https://doi.org/10.1177/019251396017003001

54.

Tarzia

(2020). “It went to the very heart of who I was as a woman”: The invisible impacts of intimate partner sexual violence. Qualitative Health Research, 31(2), 287–297. https://doi.org/10.1177/1049732320967659

55.

Thomas

Bizumic

Cruwys

Walsh

(2024). Measuring civilian moral injury: Adaptation and validation of the Moral Injury Events Scale (Civilian) and Expressions of Moral Injury Scale (Civilian). Psychological Trauma, 16(2), 270–279. doi: 10.1037/tra0001490.

56.

Weiss

Hawkins

Yarvis

J. S.

(2023). Moral injury in women military members and veterans: What do we really know? Journal of Military, Veteran and Family Health, 9(4), 129–136. https://doi.org/10.3138/jmvfh-2022-0075

57.

Williamson

Lamb

Hotopf

Raine

Stevelink

Wessely

Docherty

Madan

Murphy

Greenberg

(2023). Moral injury and psychological wellbeing in UK healthcare staff. Journal of Mental Health, 32(5), 1–9. https://doi.org/10.1080/09638237.2023.2182414

58.

Willie

T. C.

Kershaw

T. S.

(2019). An ecological analysis of gender inequality and intimate partner violence in the United States. Preventive Medicine, 118, 257–263. https://doi.org/10.1016/j.ypmed.2018.10.019