Empirical Extension of the Theory of Moral Injury: Investigating the Role of Intrapersonal Moral Injury Cognitions through Paradigmatic Models in Non- Offending Parents of Children who have Experienced Sexual Abuse.

Student thesis: Doctoral Thesis


The term moral injury has been used to describe the psychological effects of bearing witness to the occurrence and/or aftermath of violence and human suffering or failing to prevent outcomes which transgress deeply held beliefs. Non-offending parents (NOPs) can adopt maladaptive moral injury cognitions that appraise themselves as having committed moral violations for failing to protect their children from sexual abuse. The hallmark features of moral injury have been hypothesised to include the experience of guilt, shame, betrayal, emotions, and anger following the traumatic event. These emotional responses are commonly preceded by maladaptive post-trauma cognitions (i.e., negative beliefs about the self, world, and self-blame) that result from the appraisal of their child being sexually abused. In line with existing cognitive models of post-traumatic distress, NOPs appraisals of the morally injurious event and negative beliefs about themselves can contribute to the development of negative emotions and, ultimately, diagnosable mental health disorders including posttraumatic stress disorder (PTSD), complex posttraumatic stress disorder (CPTSD), depression, and other disorders. Due to a paucity of empirical research in this area, the current program of research addressed this gap by examining the relationship between intrapersonal maladaptive moral injury cognitions, PTSD, and CPTSD, as well as intrapersonal adaptive cognitive coping strategies that facilitate Post-traumatic Growth (PTG) (i.e., positive psychological changes resulting from struggling with traumatic events).

Three cognitive paradigmatic models were developed, namely the Intrapersonal Maladaptive Moral Injury Cognitions of PTSD Model; the Intrapersonal Maladaptive Moral Injury Cognitions of CPTSD Model, and the Intrapersonal Adaptive Cognitive Coping Model of Post-traumatic Growth. CPTSD is an emerging psychological disorder, and the psychometrics for the International Trauma Questionnaire (ITQ; Cloitre et al., 2018) are still evolving. Therefore, the present research examined the clinical utility of the ITQ in a population of NOPs. This current research also compared differences of maladaptive moral injury cognitions between NOPs with a diagnosis of PTSD or CPTSD with high Adverse Childhood Experiences (ACE) verses low ACE; and sought to identify the key adaptive cognitions that facilitate PTG.

Four empirical studies that utilised a mixed-methods approach were conducted to achieve the overarching aims of this research. Study 1, which employed a sample of NOPs in Australia (N = 151), found that the intrapersonal maladaptive cognitions of moral injury that predicted PTSD were: self-judgment, overidentification, and isolation relating to uncompassionate self, catastrophising relating to emotion dysregulation, and negative-self cognitions. Findings from the path analysis supported the Intrapersonal Maladaptive Moral Injury Cognitions of PTSD Model (see Figure 9) with intrapersonal maladaptive cognitions as a strong and significant predictor that explained the risk of 47% of the variance of PTSD. Study 2’s findings demonstrated the ICD-11 ITQ to be a valid and reliable measure with an Australian NOP population (N = 126). Latent class analysis identified two distinct CPTSD (34.1%) and PTSD (11.1%) profiles. Results supported the Intrapersonal Maladaptive Moral Injury Cognitions of CPTSD Model (see Figure 15) showing that intrapersonal maladaptive cognitions significantly predicted variance in PTSD (56%) in NOPs with high ACE, suggesting that moral injury related cognitions may differentiate between PTSD and CPTSD. Study 3 presented a systematic literature review of factors promoting PTG in parents of children who had experienced complex trauma. Primary findings suggested that self-compassion, positive re-appraisal, and self-esteem were growth factors that facilitated PTG outcomes across 21 studies. Study 4 revealed that intrapersonal adaptive cognitive coping strategies of PTG explained 25% of the variance in PTG (personal strength), supporting the Intrapersonal Adaptive Cognitive Coping Model of Post-traumatic Growth (see Figure 18). Mediators of PTG and PTSD included hope, self-compassion (mindfulness), emotion regulation (positive re-appraisal), and post-traumatic cognitions (negative emotions). The findings from the studies conducted in this current program of research have empirically extended moral injury theory to develop the Intrapersonal Moral Injury Cognitions Theory. Evidential support was found for the paradigmatic models that depict the clinical utility of intrapersonal cognitions of moral injury as valuable psychosocial constructs beyond solely abuse-related symptoms in PTSD, CPTSD, and PTG, holding heuristic and pragmatic value as potential therapeutic targets in treating NOPs.
Date of Award15 Jun 2022
Original languageEnglish
SupervisorPeta Stapleton (Supervisor), Alan Patching (Supervisor) & Aileen Pidgeon (Supervisor)

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