Examining Moral Injury in Legal Involved Veterans

BACKGROUND: Legal-involved Veterans (LIV) currently comprise approximately 8% of the incarcerated U.S. population, with over 180,000 veterans estimated to be in prisons or jails and a far greater number currently on parole or probation. Furthermore, LIV appear to experience heightened risk for negative sequelae such as homelessness, suicide, unemployment and psychiatric diagnoses. While various factors may contribute to these negative outcomes, the potential for exposure to potentially morally injurious experiences (PMIEs) during legal involvement and the resulting expression of moral injury as contributors have not yet been examined in this population. As a result, we adapted measures of moral injury to assess moral injury in the legal context. HYPOTHESES: 1. LIV will report exposure to PMIEs and moral injury during their legal involvement. 2. The adapted moral injury measures will demonstrate adequate psychometric strength. 3. Exposure to PMIEs and the expression of moral injury will be associated with suicidal ideation and suicide attempts. METHOD: Study participants (N=100) were recruited from the VA North Texas Health Care System. Participants were adults (age 18+) who are veterans of the U.S. armed forces and have at least one felony conviction resulting in incarceration. Patients were administered a battery of measures including the Moral Injury Events Scale (MIES) the Expressions of Moral Injury Scale (EMIS) as well as adapted versions of each measure to assess legal-related moral injury (Moral Injury Events Scale-Legal Involved Persons [MIES-LIP]; Expressions of Moral Injury Scale-Legal Involved Persons [EMIS-LIP]). Measures also included assessments of depressive symptoms (PHQ-9), PTSD symptoms (PCL-5) and suicidality (SITBI-R). We examined the psychometric properties of the adapted measures by evaluating their reliability, validity, and factor structure. We utilized multinomial logistic regression to evaluate the relationship between moral injury and suicide risk. RESULTS: The vast majority of our sample endorsed witnessing a potentially morally injurious event while in involved with the legal system and in the military. Furthermore, the majority of our sample endorsed engaging in morally injurious behavior in the legal context and in the military. Both adapted scales of moral injury (MIES-LIP & EMIS-LIP) demonstrated psychometric strength as evidence by good reliability, as well as convergent and discriminant validity with other study measures. Furthermore, the EMIS-LIP scale significantly differentiated those with a prior suicide attempt from those with no prior suicidal ideation. DISCUSSION: Legal-related moral injury appears to be a salient factor affecting many legal-involved veterans, and our adapted measures of moral injury demonstrated good reliability and validity. Furthermore, legal-related moral injury as measured by the EMIS-LIP was significantly associated with lifetime suicide attempt in LIV. Future studies should examine drivers of legal-related moral injury in LIV, which may inform future assessment and treatment.