Moral Injury as a Social Phenomenon: Looking at the Unique Relationship with System Justification

ABSTRACT

Moral Injury (MI) and Posttraumatic Stress Disorder (PTSD) are potential outcomes following combat military service which exposes veterans to a range of potentially morally injurious events (PMIEs). Given the hypothesized social nature of MI symptoms, it was predicted that System Justification, the tendency to defend and justify systems, even when they may be disadvantageous, would be uniquely related to MI, compared to PTSD. A total of 146 male combat veterans filled in questionnaires relating to PMIEs (MIES), MI (EMIS-short), PTSD symptoms (PCL-5) and System Justification (GSJS). PMIEs (self, other and betrayal related) were all related to higher levels of MI. A parallel mediation model was conducted and demonstrated that PMIEs (self) were associated with higher levels of MI and PTSD symptoms and that MI symptoms mediated the relationship between PMIEs (self) and lower System Justification. There was no mediation effect of PTSD symptoms. This relationship was strongest when veterans did not perform reserve duty and thus were not affiliated with the military. The findings support the theory that MI symptomology, as opposed to PTSD symptomology, has a greater relationship with worldviews such as the relationship to societal systems and that this is greatest when transitioned to civilian life.

KEYWORDS:

• Military
• moral injury
• posttraumatic stress disorder
• system justification
• veterans

Veterans returning from combat have often been exposed to multiple traumatic experiences which put them at an increased risk of posttraumatic stress disorder (PTSD) (Hines et al., 2014). Returning to civilian life has been associated with transition-related stressors and mental health difficulties (Alonso et al., 2021; Macmanus et al., 2014; Mobbs & Bonanno, 2018).

While fear-based traumatic events experienced in combat may lead to the development of PTSD, the multitude of trauma exposures in the military environment, coupled with poor success rates of PTSD treatments for veterans (Jordan et al., 2017) has led to the understanding that other complex, traumatic events may also have damaging psychological fallout, not limited to fear-based responses. These non-traditional PTSD-type presentations may not be captured in traditional PTSD treatments and contribute to the high levels of treatment resistant PTSD in military populations (Steenkamp et al., 2015).

Moral Injury (MI) describes the psychological distress felt when individuals perpetrate, witness, or fail to prevent actions which transgress their core moral or ethical beliefs (Litz et al., 2009). In the context of the military service, there are countless examples of potentially morally injurious events (PMIEs) including killing or wounding others, engaging in retribution or disproportionate violence, or failing to save the life of a comrade, child or civilian (Braitman et al., 2018; Currier et al., 2015; Farnsworth et al., 2017). Transgressive acts can be justified in the context of war and yet still be morally injurious (Farnsworth et al., 2014; Litz et al., 2009). These PMIEs may have an element of fear but are characterized by primary element of violation of moral or ethical standards and have been identified by unique symptom trajectories (Litz et al., 2018).

MI can lead to a range of psychological symptoms from non-pathological dissonance and inner conflict, through to resulting psychosomatic, depressive and suicidal psychopathologies (Griffin et al., 2019). The key symptoms have been identified as prolonged guilt, shame and psycho-spiritual struggles, characterized by a loss of trust, meaning and hope (Koenig et al., 2020). Moving away from a singular diagnostic structure, functional theorists have described MI as the “expanded social, psychological, and spiritual suffering stemming from costly or unworkable attempts to manage, control, or cope with the experience of moral pain” (defined as the dysphoric emotions and cognitions experienced in response to a morally injurious event) (Farnsworth et al., 2017, p. 5). Many symptoms of MI have an overlap with PTSD symptoms, though there has recently been an increase in attempts to differentiate the two presentations leading to similar conclusions that “although MI is positively correlated with PTSD, MI is not PTSD” (Koenig et al., 2020, p. 11).

Based on the currently accepted diagnosis of PTSD (American Psychiatric Association, 2013), the neurologically grounded symptoms of PTSD can be characterized by intrusion symptoms such as flashbacks and reliving the traumatic event (criterion B) and hypervigilance (criterion E) whereas MI is greater identified by symptoms from criterion D, namely negative cognitions about the self, the world and a loss of interest in activities (Koenig et al., 2020). It is believed that MI additionally may have different functional implications to seemingly overlapping symptoms such as hypervigilance (for example to betrayal as opposed to physical threat) or aggressive outbursts (to avoid shame) (Litz et al., 2022) and that in the case of MI (as opposed to classic PTSD) there may be a more delayed onset to interpersonal and functional problems experienced following discharge from the military (Maguen et al., 2020). The differentiation of MI from traditional PTSD symptoms and symptom trajectories has been identified as one of the most pressing directions of future MI research, a decade following the demarcation of the concept in the trauma psychology literature (Currier, Drescher, et al., 2020).

Drawing on these differences, particularly, related to changes in cognitions about the self and the world, one hypothesized differentiation between MI and PTSD is the effect that they have on the relationship to the social context and wider societal connections. While PTSD has been characterized by concern with individual risk and danger, MI has been associated with stronger concerns relating to the reliability and trustworthiness of others, and forgiveness of others (Boska & Capron, 2021). Indeed distortions in worldviews appear to be more prevalent in some cases of MI, even greater than the breaking of personal moral codes (C. L. Williams & Berenbaum, 2019).

System Justification Theory suggests that individuals are motivated to defend their social, political, and economical arrangements as fair and just even when at an individual disadvantage (Jost & Banaji, 1994; Jost, 2020a). System justification serves a palliative function in reducing emotional distress (Jost et al., 2008; Wakslak et al., 2007) and inducing a sense of meaning, hope, control and stability (Jost & Hunyady, 2002). Just as moral distress can be characterized by “culturally imbued, shared values” which may conflict with each other (Griffin et al., 2019, p. 357), so too does System Justification present a theory as to how members of society cope with conflicting values. System Justification theory has demonstrated repeatedly that even disadvantaged members of society will justify wider societal beliefs and practices, even if they demand the internalization of inferiority stigmas (Jost, 2020b). When inequalities, wrongdoings and injustice within the society can be justified by an individual, the theory repeatedly shows that that justification is more common than rebellious activity or discontent cognitions (Jost, 2020a). Despite the prevalence of System Justification and the palliative benefits of adhering to System Justification, there are significant individual differences in the prevalence of System Justification, particularly in regard to individual sensitivity to injustice from both a political and neurobiological investigative standpoint (Jost, 2020c).

The current study was designed to investigate the effect of military experiences which may engender such a sentiment of injustice or wrongdoing (PMIEs) and whether associated MI symptoms are associated with lower levels of System Justification. The relationship between MI and System Justification, as yet, has not been studied though there are indications that these concepts are inextricably linked. Moral emotions have been theorized to both maintain and harm social functioning depending on whether they are managed in an effective manner (Drescher & Farnsworth, 2020). A social functionalist approach to the phenomenon would indicate that managed moral emotions (i.e., guilt, shame and to a lesser extent, anger, contempt and disgust) which aid an individual to identify PMIEs as morally problematic, would serve to maintain group and dyadic relations and functioning, whereas unmanaged moral pain may have a social withdrawal function. Ineffective attempts to manage such emotions and the endurance of moral pain following changes in moral affiliation (the transition from military to civilian societal norms), characterize the development of MI in military populations (Drescher & Farnsworth, 2020). This may lead to social withdrawal and the distancing from social systems, of which veterans are members (Griffin et al., 2019) and could be described as a reduction in System Justification.

Distance from social systems, as opposed to reporting high System Justification, can be witnessed tangentially in the literature on MI. The suffering experienced due to MI amongst veterans has been associated with a loss of religious identification (Williamson et al., 2021) and veterans have reported that moral dissonance following a PMIE can lead to a disintegration of their view that during their service they were a “force for good” (Williamson et al., 2020, p. 5) with some resolving this dissonance by identifying a different source to blame such as the relevant governmental bodies (Williamson et al., 2020). The “multilayered feelings of disillusionment, abandonment, and betrayal” which develop post-deployment have been described as “organizational family betrayal,” with the experience of distancing from societal organizations such as the military and the government, experienced similarly to the disintegration of family bonds (McCormack & Ell, 2017, p. 244). This loosening of military family ties can be a catalyst for reflection on inconsistencies in deployment and further social withdrawal (McCormack & Ell, 2017).

If a relationship between System Justification and MI is evidenced, this may identify one differentiating feature between PTSD and MI diagnoses. If MI has a greater relationship to cognitive changes in worldviews and social connections, as outlined above, then it would be expected that this difference would be reflected in the separate relationship between MI and System Justification and PTSD and System Justification. Separating the two diagnoses is critical for treatment purposes. Not all veterans experience PMIEs, fewer develop MI and PTSD symptoms and the resulting effect on daily living is of varying consequence, both on an individual and societal level, as outlined above. When symptom trajectories are not equally supported, on both a research and clinical level, the neglect of one trajectory may lead to difficulties accessing treatment. When veterans with MI demonstrate little or no criterion B symptoms they may become ineligible for treatment only available to those meeting all PTSD criteria (American Psychiatric Association, 2013). Furthermore, when eligible for PTSD treatment, they may not receive appropriate treatment due to the different presentations and treatment targets for PTSD and MI. When treatment is standardized for PTSD, MI symptoms are often neglected (Borges et al., 2020). Guilt and shame cognitions, which predominate in the MI experience, appear to have little change following traditional evidence based therapies for PTSD (Finlay, 2015) and remain predictive of posttraumatic stress symptoms following treatment completion (Foa & Meadows, 1997; Owens et al., 2008).

Given the proposed differences between PTSD and MI it was predicted that a greater exposure to, or participation in,PMIEs would cause greater MI symptoms and these would predict a loss of connection and justification of societal systems as evidenced by lower System Justification. This relationship was not predicted to occur via PTSD symptoms (PTSS) which, while predicted to increase following PMIE exposure, were not predicted to influence System Justification. Finally, given the proposed effect of the transition from military service to civilian life as further increasing disillusionment and being a catalyst for reanalyzing societal ties, it was predicted that current reserve duty service would moderate the relationship between MI and System Justification and that lower System Justification would be predicted by higher MI especially in those fully detached from the military. Given the exploratory nature of the study due to lack of preexisting evidence on the relationship between System Justification and MI related factors (neither PMIEs nor resulting MI), the current study was designed as a cross-sectional preliminary analysis.

Method

The current study was part of a preregistered wider study into moral injury in an Israeli veteran population (https://osf.io/bu32y/). Research was approved by the Institutional Review Board (IRB) of Hebrew University. An a priori power analysis using G*Power 3 (Faul et al., 2007; p < .05), with a model of seven predictor variables and 0.95 statistical power as a baseline was conducted. Only four of the seven variables were central to this study’s model. The analysis revealed that a sample size of 138 participants will detect a small effect size (f_c [130] = 2.28, L = 20.70). This confirmed this study’s sample size (N = 146) was large enough for the proposed exploratory models. Participants included 146 Israeli male IDF (Israel Defense Forces) combat veterans between the ages of 27 and 44 who had completed the Peace of Mind (POM) veteran rehabilitation program upon discharge (there are no references to the concepts of moral injury and system justification in the program) (Brom et al., 2020).

Of the 441 former participants of the POM program that were approached, 167 participants responded, gave their initial consent and opened the questionnaires. Those who did not respond either didn’t pick up the phone or didn’t respond to a text message sent personally by a research assistant. Of the 167 who responded, 146 participants completed the questionnaires and were included in the final analysis. Participants were offered the chance to win one of five 200NIS ($60) vouchers following completion of the study. Participants were predominantly Jewish Israeli (93.8%) with 1 Muslim and 8 identifying as “other” for religious identity. They were also mainly married or in a long-term relationship (90.4%). Ninety-eight participants still performed reserve duty (67%), 41 no longer performed reserve duty (but had in the past) (28%) and 7 never performed reserve duty (5%).

Measures

PMIEs

The Moral Injury Events Scale (MIES; Nash et al., 2013) is a nine-item self-report questionnaire, assessing perceived violation of moral beliefs or betrayal by self or others during military experience. The MIES was used to measure PMIE exposure. Items were rated on a Likert scale from 1 (strongly disagree) to 6 (strongly agree). For each subscale the sum of the scores was used. The questionnaire opens by asking the participant “when you think of your active military experience … .” The first subscale (items 1–2) assesses perceived transgressions by others. The second subscale (items 3–6) assesses perceived transgressions by self. The third subscale (items 7–9) assesses perceived betrayal. The MIES has been translated to Hebrew, validated for use in the Israeli population, and has shown construct and convergent validity, and good internal consistency (Levi-Belz & Zerach, 2018). For the current study, internal reliability was highest for self (a = 0.82) and lower for other (Chronbach a = 0.78) and betrayal (a = 0.69) PMIEs.

Moral injury

The Expressions of Moral Injury Scale-Military-Short-Form (EMIS-M-SF; Currier, Drescher, et al., 2020) is a four-item self-report questionnaire, assessing for moral injury symptoms in military populations. Respondents were asked to indicate how much they agree or disagree with the four statements (e.g., “I am ashamed of myself because of things that I did/saw during my military service). Items were rated on a Likert scale from 1 (strongly disagree) to 5 (strongly agree). Higher total scores indicated severity of moral injury. The EMIS-M-SF has shown good convergent validity and in the current study demonstrated high internal consistency (a = 0.82). The EMIS-M-SF was translated for this study by three clinical psychologists and one psychotherapist from English to Hebrew and back-translated to ensure proper translation.

PTSS (posttraumatic stress symptoms)

The Posttraumatic Stress Disorder Checklist-5 (PCL-5; Weathers et al., 2013) is a 20-item self-report questionnaire assessing PTSD symptom severity in the past month. Responses to items measure how much a given participant has suffered from each PTSD symptom in the past month. Specifically, items asked about reactions to experiences in military service, (e.g., “I have recurrent dreams and nightmares about a stressful experience from my service”). Items were rated on a Likert scale from 1 (not at all) to 5 (extremely). PCL-5 item responses were summed for a continuous PTSD symptom score ranging from 0 to 80. Items rated 2 (moderately) or higher indicated a symptom is present. The PCL-5 has shown good convergent validity (Blevins et al., 2015; Wortmann et al., 2016). The PCL-5 has been translated to Hebrew, validated for use in the Israeli population, and in the current study items generating the total score demonstrated high internal consistency (a = 0.93).

System justification

The General System Justification Scale (GSJS; Kay & Jost, 2003) is an eight-item self-report questionnaire measuring perceptions of fairness, legitimacy, and justifiability of the social system. The questionnaire includes items such as “In general, the Israeli society is a fair society” and “Israeli society is built in such a way that people usually get what they deserve.” Responses to items were rated on a 9-point Likert scale from 1 (strongly disagree) to 9 (strongly agree). Agreement with items 1, 2, 4, 5, 6, and 8 and disagreement with items 3 and 7 indicated higher scores of system justification. Scores on the GSJS were calculated by averaging the responses to all eight items after recoding and demonstrated high internal consistency (a = 0.84). The GSJS was translated to Hebrew by Dr. Ido Liviatan and back-translated to English to ensure proper translation.

Data analysis

Data were analyzed using IBM SPSS Statistics, version 25 (IBM Corp, 2015). First the prevalence of PMIEs reported by participants were calculated. Correlations were then examined between the study variables. The study hypotheses were then examined using the PROCESS v.3.5 macro for SPSS (Hayes, 2013). First, we tested the mediating role of MI symptoms on the relationship between PMIE (self) and levels of System Justification including PMIE (others) and PMIE (betrayal) as potential covariates using a parallel mediation model (PROCESS model 4). PMIE-self was entered as the primary variable due to it having a relationship with both MI and PTSD symptoms but were PMIE-betrayal and -other seen to be significant covariates, we would have run the model for those PMIES separately. This model tests the relationship between an independent and dependent via a mediation variable and can test multiple mediation variables in parallel which enabled the inclusion of self, other and betrayal based. Based on these findings, PTSD symptoms together with MI symptoms were included as parallel mediators on the relationship between PMIE (self) and levels of system justification (PROCESS model 4). Finally, the moderation effect of reserve duty was studied using a moderated mediation model; with reserve duty considered as a moderator of the effect of MI on System Justification (PROCESS model 14). Scores were standardized prior to inclusion thus B scores in the moderation model are equivalent to β scores. Models used bias-corrected bootstraping with 5000 resamples set at a 95% confidence interval (p < .05).

Results

Frequency of PMIEs

Approximately one quarter (26%) of participants endorsed at least one PMIE by others item on the MIES, 13.7% endorsed at least one PMIE by self item, and 31.5% endorsed at least one PMIE by betrayal item (endorsement was defined as agreeing “slightly,” “moderately,” or “strongly” thus a score of 4 or higher). Seventy-one participants (48.6%) endorsed at least one item on any of the MIES subscales. The most commonly endorsed items were, “I saw things that were morally wrong,” (23.2%) and “I feel betrayed by leaders who I once trusted” (27.4%).

Correlations between study variables

Table 1 presents means, ranges, SDs, and correlations among study variables. Preliminary correlational analyses revealed that System Justification significantly negatively correlated with PMIEs performed by others (r=–.19, p < .05) and MI (r = −0.25, p < .01). MI significantly positively correlated with all subtypes of PMIEs with the highest correlation to those performed by self (r = 0.38, p < .01), by others (r = 0.33, p < .01) and lowest by perceived betrayal (r = 0.17, p < .05) and PTSD symptoms (r = 0.26, p < .01). Chi² test of association indicated that there were no correlations between reserve duty and MI while there was a correlation between reserve duty and System Justification (x² = 61.84, p = .03). The lack of relationship between PTSD symptoms and System Justification as opposed to the relationship witnessed between MI and System Justification provided preliminary support for our hypothesis of a unique symptom trajectory. Furthermore, support was also given for the relationship between distancing from the military through lack of reserve duty and lower System Justification. Correlations were repeated for only those participants with clinical PTSD (N = 18) and even with the small sample size, MI was correlated with SJ (r = −0.48, p = .04) while no correlation was observed for PTSD symptoms (p = .18).

Table 1. Correlations and DescriptiveSstatistics for study variables.

	Mean (Range)	SD	1	2	3	4	5	6
1) PMIE others	4.01 (2–12)	2.37	1
2) PMIE self	5.98 (4–20)	3.21	.59**	1
3) PMIE betrayal	5.80 (3–18)	3.36	.32**	.38**	1
4) MI	6.21 (4–20)	2.92	.33**	.38**	.17*	1
5) PTSD symptoms (PCL)	15.94 (0–60)	13.55	0.11	.29**	.34**	.26**	1
6) SJ	4.65 (1–8)	1.53	−.19*	−0.01	−0.12	−.25**	−.13	1

Mediation role of MI and PTSD symptoms on PMIE (self) and system justification

A parallel mediation model (model 4 in PROCESS) was calculated to assess the mediation effect of MI and PTSD symptoms on the relationship between PMIEs (self) and System Justification. PMIEs (others) and PMIEs (betrayal) were entered as covariates, but while PMIESs (other) had a significant direct relationship with System Justification, PMIE (betrayal) was not significant. Covariates were thus excluded from the final mediation model.

As demonstrated in Figure 1, results indicated that more PMIEs (self) were associated with higher MI (B = .34, SE=.07, 95% CIs [.20, .49], β = .39, p < .01) and PTSD symptoms (B = .1.19, SE=.34, 95% CIs [.51, .1.86], β = .29, p < .01). Higher MI was, in turn associated with reduced System Justification (B = .14, SE=.05, 95% Cis [−.24, −.05], β = .27, p < .01). These results support a full mediational hypothesis as PMIEs (self) were not associated with System Justification without the mediating effect of MI (B = .06 SE=.04, 95% Cis [−.03, .15], β = .12, p = .18). PTSD symptoms were not a mediator (B=−.01, SE=.01, 95% Cis [−.03, .01], β=-.09, p = .30). The total model accounted for 8% of the variance in System Justification. The indirect effect was tested using 5000 bootstrap samples for percentile bootstrap confidence intervals and indicated that the total indirect effect was −.13, 95% Cis [−.26, −.05].

Figure 1. Mediation of MI and PTSD Symptoms (PTSS) on the Relationship between PMIE-Self and System Justification.

Note: The coefficients are standardized. ** p<.001

Moderation effect of reserve duty on system justification

PTSD symptoms were not included in the final model (model 14, moderated mediation model) due to their lack of relationship to System Justification. There was no significant moderation effect of reserve duty on the development of MI following PMIEs (self) thus this model is not presented. The final model is presented in Figure 2.

Figure 2. Conditional Indirect Effects of PMIEs (self) and System Justification (SJ) via MI, for those Participating in and not Participating in Reserve Duty.

The coefficients are standardized. ** p < .001

As in the previous model, PMIEs (self) were associated with higher MI (B = .38, SE=.08, 95% Cis [.23, .53], p < .01). Reserve duty moderated the association between MI and System Justification (interaction B=−.52, SE=.18,t = −3.0, p = .01). The overall moderated mediation effect was tested using 5000 bootstrap samples for percentile bootstrap confidence intervals and indicated that the total indirect effect was .19, 95% Cis [.04, .37]. The relationship, (see Figure 3), between MI and System Justification was only significant for those not participating in reserve duty (effect=−.63, SE=.15, 95% CIs [−.93, −.33], p < .01). For those participating in reserve duty there was no relationship between MI and System Justification (effect=−.09, SE=.09, 95% CIs [−.28, −.09], p < .29). The total model accounted for 15% of the variance in System Justification.

Figure 3. Relationship between MI and SJ for those still in Reserve Duty and those not in Active Reserve Duty.

Discussion

The trajectory of MI symptomology has been weakly explored in the literature (but see Maguen et al., 2020 for a notable exception). The current study was designed to assess the hypothesis that MI is a social phenomenon and as such differentiate MI and PTSD symptoms in their relationship with the justification of social systems (System Justification). The current study demonstrated, as predicted, that PMIEs perpetrated by a veteran during the course of his military experience were associated with increased MI and PTSD symptoms. While higher MI symptoms were associated with lower levels of System Justification, PTSD symptoms were not associated with System Justification. MI symptoms were only associated with lower levels of System Justification when the combat veteran was not still in reserve duty. Witnessed PMIEs performed by others were directly associated with lower System Justification.

The findings reinforce the distinction between MI and PTSD symptom structures and the potential for different symptom implications. In accordance with the theories of MI relating to social withdrawal and distancing from social systems (Griffin et al., 2019), this distance from social systems was uniquely related to MI and not PTSD symptomologies. Low System Justification is demonstrated by a disillusionment and lack of faith in societal systems and while this directly related to the experience of witnessing others commit PMIEs in the military, the development of MI following self-perpetrated PMIEs fully mediated the relationship to System Justification. There has been little research into predictors of System Justification, with the majority of System Justification research focused on why disadvantaged groups continue to support unfair systems of authority (Jost, 2020a), for example amongst disadvantaged mothers (Godfrey, 2013). Factors such as system dependence, inescapability and low personal control have been related to higher System Justification but other than high illegitimacy of systems, few factors have been related in declines in System Justification (Kay & Friesen, 2011).

In our current study we introduced the element of moral pain, MI, as related to lower System Justification. Indeed, rather than overt illegitimacy of social and governmental systems (as studied previously) moral pain related to a specific social system (the military) appears to be associated with lower SJ in relation to wider social systems (general System Justification). The implications of MI are thus both on an individual and societal level.

On an individual level, lower System Justification may enhance the emotional distress experienced due to MI by enhancing the sense of social withdrawal and loneliness associated with MI and this may further contribute to the strong association between MI and depression and in turn suicidality (Levi-Belz & Zerach, 2018; Wisco et al., 2017). As has been studied previously, the relationship between suicidality and MI can be mediated by a sense of entrapment (J. M. Williams, 1997; Levi-Belz & Zerach, 2018) and this may be confounded by a sense of hopelessness and despair relating to societal systems. As Jonathan Shay, a military psychiatrist writes, “Primarily, it (MI) destroys the capacity for social trust in the mental and social worlds of the service member or veteran. I regard this as a kind of wound contamination in the mind, preventing healing and leaking toxins” (Shay, 2011, p. 184).

On a societal level, while military service is commonly believed to strengthen national identity (Krebs, 2004), the current study indicates that this may be dependent on the PMIEs the veteran is exposed to throughout his service, and in particular, the moral distress which ensues. This has implications for a society which, in part, builds its national identity on the importance and respect given to its military service. Like most other Western societies, the Israeli military is no longer a “people’s army” in that it no longer has the same social binds which it once had when Israel was in a state of creation, at immediate risk and dissent was almost unheard of (Tamari, 2016). While the motto of the IDF education corps is still “am bone tzava bone am” (the people build the army builds the people), it appears that loyalty to the systems upon which the country functions, may be dependent on the individual’s military experience. Indeed certain, morally injurious military experiences may reduce loyalty to these systems, System Justification. Not only is disquiet with the military prevalent (in the current sample, 31% experienced some element of betrayal by their commanders or the military institution), but PMIEs witnessed or performed is also related to an increased disquiet with wider societal systems. These findings corroborate Levy and Mizrahi’s theories on the dissolution of the republican discourse surrounding the military and the subsequent emergence of “protest politics” (Levy & Mizrahi, 2008, p. 40).

The findings of the current study supported the hypothesis that the relationship between MI and lower System Justification would be most apparent for those who have completely distanced themselves from army service. It was hypothesized that the full transition to civilian life induces reflective ethical questioning including an analysis of the societal systems and that this would thus cause the strongest relationship between MI and System Justification. This theory was reflected in our findings and also reinforces the theory that the cognitive dissonance experienced through MI, especially perpetrated or omitted by the self, can be resolved by attributing failures to external sources (Litz et al., 2009). Indeed, it has been hypothesized that the distress, loss of significance and loss of subjective meaning associate with MI is similar to the psychological state which has been associated with radicalization including extremist views related to societal systems (Williamson et al., 2021). Externalizing blame and projecting anger on external systems can reflect a narrowing of an individual’s moral systems and reducing ties with wider societal systems (Farnsworth et al., 2014). This it appears is most apparent when not bound to one of the most prevalent societal systems, the military. On the other hand, given the cross-sectional nature of the study we cannot be sure that it is not the reduced System Justification which causes the termination of reserve duty. If this were the case, it is surprising that no moderation effect of reserve duty was seen between PMIEs committed by the self and MI given the more direct relationship between the military institution and moral pain from the military experience.

While the strength of the current study lies in its novelty in studying social phenomenon within the context of what could be considered a uniquely social disorder, the current study suffered from the limitations inherent within cross sectional research. Despite using a statistical tool designed for causational measurement, we are only able to confidently declare associations between the study measures. Future studies must follow military recruits from recruitment through to post-discharge and only then would causational hypotheses be testable. Given the associations witnessed in the current study, social theories such as System Justification would be a welcome addition to longitudinal MI research and reflect the scope of MI in affecting individual and societal beliefs.

Another limitation of the current study is the small sample size. While the sample size was deemed suitable for detecting a small effect size, wider sampling would offer a wider variation in MI, PTSD and System Justification scores strengthening the effect witnessed. MI and PTSD mean scores were expectedly low in the current sample given the non-clinical nature of the population and recruiting samples with a higher propensity for PTSD and MI symptoms may offer greater variation. PTSD symptoms were studied dimensionally rather than using a clinical diagnosis and thus this limits the generalizability of the current study to clinical populations.

While the study aimed to differentiate between PTSD and MI symptom profiles in their relationship to System Justification, it is important to note that there is still inherent overlap between the two conditions, and while the EMIS-M-SF did not overlap with PTSD symptoms, criterion D questions on the PCL-5 include elements of MI. It is important to note that a major limitation of this study, and inherent in early MI research, is that MI and PTSD are not pure, distinct constructs. The current sample offered an introduction to a veteran population in a modern society built on military foundations undergoing societal change and in part, the strength of the current sample is in the predominantly non pathological participant recruitment which enables application to a general population. Further studies should include recruitment of a comparison pathological population which could aid understanding of the extent of strength of the relationship between MI and PTSD symptoms and System Justification. Given that System Justification has been studied extensively in disadvantaged populations, including a wider disadvantaged population would also enable comparison with other population groups studied in relation to System Justification.

Conclusion

The current study demonstrated the unique relationship between PMIEs performed by veterans, in the course of their army service, their subsequent MI symptoms and lower System Justification. This was seen specifically in those who no longer perform reserve duty. Despite the limitations of the cross-sectional nature of the study, this is the first study to hypothesize and provide initial evidence for a connection between System Justification and MI, highlighting the uniquely social nature of MI symptoms. The current findings require further validation with longitudinal analysis of changes in societal affiliations and cognitions from pre to post military service though the current study provides motivation to uniquely focus on the relationship between PMIEs, MI development and subsequent changes in societal affiliations.

Ethical standards and informed consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation from Hebrew University and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients for being included in the study.

Acknowledgments

With thanks to Ester Benhamou and Prof. Ruth Pat-Horenczyk for their contribution in planning and performing the study and Nadav Stern for data management.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The study was partially funded by a grant from the Paul Baerwald School of Social Work and Social Welfare.