Moral Injury Appraisals and Complex PTSD in Refugees : A Longitudinal Study

Objective: Refugees show elevated rates of complex posttraumatic stress disorder (CPTSD). However, relatively little is known regarding the psychological mechanisms that underlie the association between exposure to potentially traumatic events (PTEs) and CPTSD following exposure to war, persecution and displacement. In this study, we investigated the potential mediating role of moral injury appraisals (cognitive appraisals regarding the experience and consequences of morally transgressive events) in the association between PTE exposure, posttraumatic stress disorder (PTSD), and disturbances in self-organization (DSO) symptoms. 

Method: Participants were 889 refugees from Arabic-, Farsi-, Tamil-, and English-speaking backgrounds who completed an online survey in their own language at two time points 12 months apart. We assessed PTE exposure, moral injury-other appraisals (appraising moral transgressions as enacted by others), moral injury-self appraisals (appraising moral transgressions as enacted by the self), PTSD symptoms, and DSO symptoms. 

Results: Longitudinal structural equation modeling indicated that moral injury-other appraisals mediated the association between PTE exposure and both PTSD and DSO symptoms. In contrast, moral injury-self appraisals only mediated the association between PTE exposure and DSO symptoms. 

Conclusions: Findings highlight the role of moral injury appraisals in exacerbating traditional PTSD symptoms, as well as the broader symptoms characteristic of CPTSD. Further, results indicate that specific types of moral injury appraisals (relating to one’s own and others’ perceived moral transgressions) may lead to differential psychological reactions, raising important implications for clinical practice.

Clinical Impact Statement

Appraising potentially traumatic events as morally transgressive was associated with greater symptoms of posttraumatic stress disorder (PTSD) and complex PTSD in refugees. Specifically, we found that stronger appraisals relating to others’ moral transgressions were related to greater PTSD symptoms and disturbances in self-organization in refugees. In contrast, stronger appraisals relating to refugees’ own transgressions were related to greater disturbances in self-organization (but not PTSD) symptoms. These findings suggest that moral injury appraisals are an important clinical target for reducing psychological symptoms in refugees. Further, results underscore the utility of considering both moral transgressions relating to one’s own and others’ actions when providing psychological treatment to refugees.