Hostname: page-component-848d4c4894-jbqgn Total loading time: 0 Render date: 2024-06-15T00:59:39.727Z Has data issue: false hasContentIssue false
  • English
  • Français

The longitudinal association between moral injury appraisals and psychological outcomes in refugees

Published online by Cambridge University Press:  02 December 2020

Angela Nickerson Open the ORCID record for Angela Nickerson [Opens in a new window] ,
Yulisha Byrow ,
Joel Hoffman ,
Meaghan O'Donnell ,
Richard A Bryant ,
Natalie Mastrogiovanni ,
Tadgh McMahon ,
Greg Benson ,
Vicki Mau  and
Belinda J. Liddell
Angela Nickerson*
Affiliation:
School of Psychology, University of New South Wales, Sydney, NSW Australia
Yulisha Byrow
Affiliation:
School of Psychology, University of New South Wales, Sydney, NSW Australia
Joel Hoffman
Affiliation:
School of Psychology, University of New South Wales, Sydney, NSW Australia
Meaghan O'Donnell
Affiliation:
Phoenix Australia, University of Melbourne, Parkville, VIC, Australia
Richard A Bryant
Affiliation:
School of Psychology, University of New South Wales, Sydney, NSW Australia
Natalie Mastrogiovanni
Affiliation:
School of Psychology, University of New South Wales, Sydney, NSW Australia
Tadgh McMahon
Affiliation:
Settlement Services International, Ashfield, NSW, Australia Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
Greg Benson
Affiliation:
Settlement Services International, Ashfield, NSW, Australia
Vicki Mau
Affiliation:
Australian Red Cross, North Melbourne, VIC, Australia
Belinda J. Liddell
Affiliation:
School of Psychology, University of New South Wales, Sydney, NSW Australia
*
Author for correspondence: Angela Nickerson, E-mail: anickerson@psy.unsw.edu.au
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Refugees report a diverse array of psychological responses following persecution and displacement. Little is known, however, regarding the mechanisms that underlie differential psychological reactions in refugees. This study investigated the longitudinal impact of negative moral appraisals about one's own actions [i.e. moral injury-self (MI-self) appraisals] and others' actions [i.e. moral injury-other (MI-others) appraisals] on a variety of psychological symptoms over a period of 6 months.

Methods

Participants were 1085 Arabic, Farsi, Tamil, or English-speaking refugees who completed a survey at baseline and 6 months later either on-line or via pen-and-paper. The survey indexed demographic factors, exposure to potentially traumatic events (PTEs), exposure to ongoing stressors, MI-other appraisals, MI-self appraisals, re-experiencing and arousal symptoms, and feelings of sadness, anger and shame.

Results

Findings indicated that, after controlling for demographics, PTE exposure and ongoing stressors, MI-other appraisals predicted increased re-experiencing and hyperarousal symptoms, and feelings of sadness and shame. MI-self appraisals predicted decreased feelings of shame, and decreased re-experiencing symptoms. In contrast, psychological symptoms at baseline did not as strongly influence MI appraisals 6 months later.

Conclusions

These findings highlight the important role that cognitive appraisals of adverse events play in the longitudinal course of psychological symptoms. These results thus have important implications for the development of tailored psychological interventions to alleviate the mental health burden held by refugees.

Keywords

Refugeesmoral injuryposttraumatic stressdepressionanger
Type
Original Article
Information
Psychological Medicine , Volume 52 , Issue 12 , September 2022 , pp. 2352 - 2364
Check for updates
Copyright
Copyright © The Author(s), 2020. Published by Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Agger, I. (1989). Sexual torture of political prisoners: An overview. Journal of Traumatic Stress, 2(3), 305–318.CrossRefGoogle Scholar
American Psychiatric Association, (2013). Diagnostic and statistical manual of mental disorders, 5th edn. Arlington, VA: American Psychiatric Association.CrossRefGoogle Scholar
Basoglu, M., Livanou, M., Crnobaric, C., Franciskovic, T., Suljic, E., Duric, D., & Vranesic, M. (2005). Psychiatric and cognitive effects of war in former Yugoslavia: Association of lack of redress for trauma and posttraumatic stress reactions. Journal of the American Medical Association, 294(5), 580–590, + .CrossRefGoogle ScholarPubMed
Basoglu, M., & Mineka, S. (1992). The role of uncontrollable and unpredictable stress in post-traumatic stress responses in torture survivors. In Basoglu, M. (Ed.), Torture and its consequences: Current treatment approaches. Cambridge University Press: Cambridge, UK.Google Scholar
Brewin, C. R., Dagleish, T., & Joseph, S. (1996). A dual representation theory of posttraumatic stress disorder. Psychological Review, 103(4), 670–686.CrossRefGoogle ScholarPubMed
Bryan, C. J., Bryan, A. O., Anestis, M. D., Anestis, J. C., Green, B. A., Etienne, N., … Ray-Sannerud, B. (2015). Measuring moral injury: Psychometric properties of the moral injury events scale in two military samples. Assessment, 23, 557–570. doi:10.1177/1073191115590855.CrossRefGoogle ScholarPubMed
Chaplo, S. D., Kerig, P. K., & Wainryb, C. (2019). Development and validation of the moral injury scales for youth. Journal of Traumatic Stress, 32(3), 448–458. doi:10.1002/jts.22408CrossRefGoogle ScholarPubMed
Charlson, F., van Ommeren, M., Flaxman, A., Cornett, J., Whiteford, H., & Saxena, S. (2019). New WHO prevalence estimates of mental disorders in conflict settings: A systematic review and meta-analysis. Lancet (London, England), 394(10194), 240–248. doi:10.1016/S0140-6736(19)30934-1CrossRefGoogle ScholarPubMed
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. doi:10.1002/cpp.2170CrossRefGoogle ScholarPubMed
Currier, J. M., Holland, J. M., Drescher, K., & Foy, D. (2015). Initial psychometric evaluation of the Moral Injury Questionnaire–Military version. Clinical Psychology & Psychotherapy, 22(1), 54–63. doi:10.1002/cpp.1866CrossRefGoogle ScholarPubMed
Currier, J. M., McDermott, R. C., Farnsworth, J. K., & Borges, L. M. (2019). Temporal associations between moral injury and posttraumatic stress disorder symptom clusters in military veterans. Journal of Traumatic Stress, 32(3), 382–392. doi:10.1002/jts.22367CrossRefGoogle ScholarPubMed
Delahanty, D. L., Herberman, H. B., Craig, K. J., Hayward, M. C., Fullerton, C. S., Ursano, R. J., & Baum, A. (1997). Acute and chronic distress and posttraumatic stress disorder as a function of responsibility for serious motor vehicle accidents. Journal of Consulting and Clinical Psychology, 65(4), 560–567. Retrieved from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=9256556.CrossRefGoogle ScholarPubMed
Dunmore, E., Clark, D. M., & Ehlers, A. (1999). Cognitive factors involved in the onset and maintenance of posttraumatic stress disorder (PTSD) after physical or sexual assault. Behaviour Research and Therapy, 37(9), 809–829. doi:S0005-7967(98)00181-8 [pii]CrossRefGoogle ScholarPubMed
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38(4), 319–345. doi:S0005-7967(99)00123-0 [pii]CrossRefGoogle ScholarPubMed
Ekblad, S., Prochazka, H., & Roth, G. (2002). Psychological impact of torture: A 3-month follow-up of mass-evacuated Kosovan adults in Sweden. Lessons learnt for prevention. Acta Psychiatrica Scandinavica Supplement, 106, 30–36.CrossRefGoogle Scholar
Farnsworth, J. K. (2019). Is and ought: Descriptive and prescriptive cognitions in military-related moral injury. Journal of Traumatic Stress, 32(3), 373–381. doi: 10.1002/jts.22356CrossRefGoogle ScholarPubMed
Farnsworth, J. K., Drescher, K. D., Evans, W. D., & Walser, R. D. (2017). A functional approach to understanding and treating military-related moral injury. Journal of Contextual Behavioral Science, 6, 391–397.CrossRefGoogle Scholar
Farnsworth, J. K., Drescher, J. A., Nieuwsma, J. A., Walser, R. B., & Currier, J. M. (2014). The role of moral emotions in military trauma: Implications for the study and treatment of moral injury. Review of General Psychology, 18, 249–262.CrossRefGoogle Scholar
Flora, D. B., & Curran, P. J. (2004). An empirical evaluation of alternative methods of estimation for confirmatory factor analysis with ordinal data. Psychological Methods, 9(4), 466–491. doi:10.1037/1082-989X.9.4.466CrossRefGoogle ScholarPubMed
Foa, E. B. (1996). Posttraumatic diagnostic manual. National Computer Systems: Minneapolis, USA.Google Scholar
Foa, E. B., Ehlers, A., Clark, D. M., Tolin, D. F., & Orsillo, S. M. (1999). The posttraumatic cognitions inventory: Development and validation. Psychological Assessment, 11, 303–314.CrossRefGoogle Scholar
Foa, E. B., & Rothbaum, B. O. (1998). Treating the trauma of rape: Cognitive behavioural therapy for PTSD. Guilford Press: New York, US.Google Scholar
Foa, E. B., Zinbarg, R., & Rothbaum, B. O. (1992). Uncontrollability and unpredictability in post-traumatic stress disorder: An animal model [research support, U.S. Gov't, P.H.S. Review]. Psychological Bulletin, 112(2), 218–238, Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/1454893.CrossRefGoogle Scholar
Forbes, D., Alkemade, N., Hopcraft, D., Hawthorne, G., O'Halloran, P., Elhai, J. D., … Lewis, V. (2014). Evaluation of the dimensions of anger reactions-5 (DAR-5) scale in combat veterans with posttraumatic stress disorder. Journal of Anxiety Disorders, 28(8), 830–835. doi:10.1016/j.janxdis.2014.09.015CrossRefGoogle ScholarPubMed
Frankfurt, S., Anders, S. L., James, L. M., Engdahl, B., & Winskowski, A. M. (2015). Evaluating the dimensionality of PTSD in a sample of OIF/OEF veterans. Psychological Trauma, 7(5), 430–436. doi:10.1037/tra0000012CrossRefGoogle Scholar
Frazier, P. A. (2003). Perceived control and distress following sexual assault: A longitudinal test of a new model. Journal of Personality and Social Psychology, 84(6), 1257–1269, Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12793588.CrossRefGoogle ScholarPubMed
Frazier, A. L., Bergman, M., & Steward, J. (2002). Perceived control and posttraumatic stress: A temporal model. Applied and Preventive Psychology, 10, 207–223.CrossRefGoogle Scholar
Graham, J., Meindl, P., Beall, E., Johnson, K. M., & Zhang, L. (2016). Cultural differences in moral judgment and behavior, across and within societies. Current Opinion in Psychology, 8, 125–130. doi:10.1016/j.copsyc.2015.09.007CrossRefGoogle ScholarPubMed
Gray, M. J., Schorr, Y., Nash, W., Lebowitz, L., Amidon, A., Lansing, A., … Litz, B. T. (2012). Adaptive disclosure: An open trial of a novel exposure-based intervention for service members with combat-related psychological stress injuries. Behavior Therapy, 43(2), 407–415. doi:10.1016/j.beth.2011.09.001CrossRefGoogle ScholarPubMed
Haldane, J., & Nickerson, A. (2016). The impact of interpersonal and noninterpersonal trauma on psychological symptoms in refugees: The moderating role of gender and trauma type. Journal of Traumatic Stress, 29(5), 457–465. doi:10.1002/jts.22132CrossRefGoogle ScholarPubMed
Harder, D. H., & Zalma, A. (1990). Two promising shame and guilt scales: A construct validity comparison. Journal of Personality Assessment, 55(3–4), 729–745. doi:10.1080/00223891.1990.9674108CrossRefGoogle ScholarPubMed
Hassija, C. M., & Gray, M. J. (2013). Adaptive variants of controllability attributions among survivors of sexual assault. International Journal of Cognitive Therapy, 6, 342–357.CrossRefGoogle Scholar
Hickling, E. J., Blanchard, E. B., Buckley, T. C., & Taylor, A. E. (1999). Effects of attribution of responsibility for motor vehicle accidents on severity of PTSD symptoms, ways of coping, and recovery over six months. Journal of Traumatic Stress, 12(2), 345–353. doi: 10.1023/A:1024784711484CrossRefGoogle ScholarPubMed
Hinton, D., Hinton, S., Um, K., Chea, A., & Sak, S. (2002). The Khmer ‘Weak heart’ syndrome: Fear of death from palpitations. Transcultural Psychiatry, 39(3), 323–344. doi:10.1177/136346150203900303CrossRefGoogle ScholarPubMed
Hinton, D. E., Rasmussen, A., Nou, L., Pollack, M. H., & Good, M. J. (2009). Anger, PTSD, and the nuclear family: A study of Cambodian refugees. Social Science and Medicine, 69(9), 1387–1394. doi:S0277-9536(09)00547-4 [pii] 10.1016/j.socscimed.2009.08.018CrossRefGoogle ScholarPubMed
Hoffman, J., Liddell, B., Bryant, R. A., & Nickerson, A. (2018). The relationship between moral injury appraisals, trauma exposure, and mental health in refugees. Depression and Anxiety, 35, 1030–1039. doi:10.1002/da.22787.CrossRefGoogle ScholarPubMed
Hoffman, J., Liddell, B., Bryant, R. A., & Nickerson, A. (2019). A latent profile analysis of moral injury appraisals in refugees. European Journal of Psychotraumatology, 10(1), 1686805. doi:10.1080/20008198.2019.1686805CrossRefGoogle ScholarPubMed
Holliday, R., Holder, N., & Suris, A. (2018). Reductions in self-blame cognitions predict PTSD improvements with cognitive processing therapy for military sexual trauma-related PTSD. Psychiatry Research, 263, 181–184. doi:10.1016/j.psychres.2018.03.007CrossRefGoogle ScholarPubMed
Hu, L., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling, 6, 1–55.CrossRefGoogle Scholar
Jinkerson, D. (2016). Defining and assessing moral injury: A syndrome perspective. Traumatology, 22, 122–130.CrossRefGoogle Scholar
Jordan, A. H., Eisen, E., Bolton, E., Nash, W. P., & Litz, B. T. (2017). Distinguishing war-related PTSD resulting from perpetration- and betrayal-based morally injurious events. Psychological Trauma, 9(6), 627–634. doi:10.1037/tra0000249CrossRefGoogle ScholarPubMed
Kopacz, M. S., Connery, A. L., Bishop, T. M., Bryan, C. J., Drescher, K. D., Currier, J. M., & Pigeon, W. R. (2016). Moral injury: A new challenge for complementary and alternative medicine. Complementary Therapies in Medicine, 24, 29–33. doi: 10.1016/j.ctim.2015.11.003CrossRefGoogle ScholarPubMed
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2002). The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms. Psychosomatic Medicine, 64, 258–266.CrossRefGoogle ScholarPubMed
Kuong, D. T. (1988). Victims of violence in the South China Sea. In Miserez, D. (Ed.), Refugees - the trauma of exile: The humanitarian role of Red cross and Red crescent (pp. 18–38). Martinus Nijhoff: Leiden, Netherlands.Google Scholar
Kushner, M. G., Riggs, D. S., Foa, E. B., & Miller, S. M. (1993). Perceived controllability and the development of posttraumatic stress disorder (PTSD) in crime victims. Behaviour Research and Therapy, 31(1), 105–110. doi:0005-7967(93)90048-Y [pii]CrossRefGoogle Scholar
Lancaster, S. L. (2018). Negative outcomes after morally injurious experiences: A replication and extension. Psychological Trauma, 10(4), 456–462. doi: 10.1037/tra0000341CrossRefGoogle Scholar
Lancaster, S. L., & Erbes, C. R. (2017). Importance of moral appraisals in military vetereans. Traumatology, 23, 317–322.CrossRefGoogle Scholar
Le, L., Morina, N., Schnyder, U., Schick, M., Bryant, R. A., & Nickerson, A. (2018). The effects of perceived torture controllability on symptom severity of posttraumatic stress, depression and anger in refugees and asylum seekers: A path analysis. Psychiatry Research, 264, 143–150. doi:10.1016/j.psychres.2018.03.055CrossRefGoogle ScholarPubMed
Lindstrom, B., Jangard, S., Selbing, I., & Olsson, A. (2017). The role of a “common is moral” heuristic in the stability and change of moral norms. Journal of Experimental Psychology General, 147, 228–242.CrossRefGoogle ScholarPubMed
Litz, B. T., Contractor, A. A., Rhodes, C., Dondanville, K. A., Jordan, A. H., Resick, P. A., … Consortium, S. S. (2018). Distinct trauma types in military service members seeking treatment for posttraumatic stress disorder. Journal of Traumatic Stress, 31(2), 286–295. doi: 10.1002/jts.22276CrossRefGoogle ScholarPubMed
Litz, B. T., & Kerig, P. K. (2019). Introduction to the special issue on moral injury: Conceptual challenges, methodological issues, and clinical applications. Journal of Traumatic Stress, 32(3), 341–349. doi:10.1002/jts.22405CrossRefGoogle Scholar
Litz, B. T., Lebowitz, L., Gray, M. J., & Nash, W. P. (2017). Adaptive discosure: A new treatment for military trauma, loss and moral injury. Guilford Press: New York, US.Google Scholar
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695–706. doi:10.1016/j.cpr.2009.07.003CrossRefGoogle ScholarPubMed
LoSavio, S. T., Dillon, K. H., & Resick, P. A. (2017). Cognitive factors in the development, maintenance, and treatment of post-traumatic stress disorder. Current Opinion in Psychology, 14, 18–22. doi:10.1016/j.copsyc.2016.09.006CrossRefGoogle ScholarPubMed
McLean, C. P., Zang, Y., Gallagher, T., Suzuki, N., Yarvis, J. S., Litz, B. T., … Consortium, S. S. (2019). Trauma-Related cognitions and cognitive emotion regulation as mediators of PTSD change among treatment-seeking active-duty military personnel With PTSD. Behavior Therapy, 50(6), 1053–1062. doi:10.1016/j.beth.2019.03.006CrossRefGoogle ScholarPubMed
Miller, S. C. (2009). Moral injury and relational harm: Analyzing rape in Darfur. Journal of Social Philosophy, 40, 504–523.CrossRefGoogle Scholar
Mollica, R. F., Caspi-Yavin, Y., Bollini, P., Truong, T., Tor, S., & Lavelle, J. (1992). The Harvard Trauma Questionnaire. Validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. Journal of Nervous and Mental Disease, 180(2), 111–116, Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/1737972.CrossRefGoogle ScholarPubMed
Muthen, B. O., & Muthen, L. (1998–2019). Mplus version 8.Google Scholar
Myyry, L., Juujarvi, S., & Pesso, K. (2013). Change in values and moral reasoning during higher education. European Journal of Developmental Psychology, 10, 269–284.CrossRefGoogle Scholar
Nash, W. P., & Litz, B. T. (2013). Moral injury: A mechanism for war-related psychological trauma in military family members. Clinical Child and Family Psychology Review, 16(4), 365–375. doi:10.1007/s10567-013-0146-yCrossRefGoogle ScholarPubMed
Nazarov, A., Fikretoglu, D., Liu, A., Thompson, M., & Zamorski, M. A. (2018). Greater prevalence of post-traumatic stress disorder and depression in deployed Canadian armed forces personnel at risk for moral injury. Acta Psychiatrica Scandinavica, 137(4), 342–354. doi: 10.1111/acps.12866CrossRefGoogle ScholarPubMed
Nickerson, A., Hoffman, J., Schick, M., Schnyder, U., Bryant, R. A., & Morina, N. (2018). A longitudinal investigation of moral injury appraisals amongst treatment-seeking refugees. Frontiers in Psychiatry, 9, 667. doi:10.3389/fpsyt.2018.00667CrossRefGoogle ScholarPubMed
Nickerson, A., Schnyder, U., Bryant, R. A., Schick, M., Mueller, J., & Morina, N. (2015). Moral injury in traumatized refugees. Psychotherapy and Psychosomatics, 84, 122–123.CrossRefGoogle ScholarPubMed
O'Donnell, M. L., Elliott, P., Wolfgang, B. J., & Creamer, M. (2007). Posttraumatic appraisals in the development and persistence of posttraumatic stress symptoms. Journal of Traumatic Stress, 20(2), 173–182. doi:10.1002/jts.20198CrossRefGoogle ScholarPubMed
Organization, W. H. (n.d.). Process of translation and adaptation of instruments. http://www.who.int/substance_abuse/research_tools/translation/en/Google Scholar
Protection, A. G. D. o. I. a. B. (2014a). Asylum statustics - Australia; Quarterly tables – June quarter 2014. A. G. D. o. I. a. B. Protection. Retrieved from https://www.homeaffairs.gov.au/ReportsandPublications/Documents/statistics/asylum-statistics-aus-jun-qtr-2014.pdf.Google Scholar
Protection, A. G. D. o. I. a. B. (2014b). Australia's migration trends 2013 to 2014. Retrieved from https://www.homeaffairs.gov.au/ReportsandPublications/Documents/statistics/migration-trends13-14.pdf.Google Scholar
Protection, D. o. I. a. B. (2013). 2012–2013 Asylum Trends in Australia.Google Scholar
Resick, P. A., & Schnicke, M. K. (1992, Oct). Cognitive processing therapy for sexual assault victims. Journal of Consulting and Clinical Psychology, 60(5), 748–756. doi:10.1037/0022-006X.60.5.748CrossRefGoogle Scholar
Sadler, G. R., Lee, H. C., Lim, R. S., & Fullerton, J. (2010). Recruitment of hard-to-reach population subgroups via adaptations of the snowball sampling strategy. Nursing & Health Sciences, 12(3), 369–374. doi:10.1111/j.1442-2018.2010.00541.xCrossRefGoogle ScholarPubMed
Schorr, Y., Stein, N. R., Maguen, S., Barnes, J. B., Bosch, J., & Litz, B. T. (2018). Sources of moral injury among war veterans: A qualitative evaluation. Journal of Clinical Psychology, 74(12), 2203–2218. doi:10.1002/jclp.22660CrossRefGoogle ScholarPubMed
Schumm, J. A., Dickstein, B. D., Walter, K. H., Owens, G. P., & Chard, K. M. (2015). Changes in posttraumatic cognitions predict changes in posttraumatic stress disorder symptoms during cognitive processing therapy. Journal of Consulting and Clinical Psychology, 83(6), 1161–1166. doi:10.1037/ccp0000040CrossRefGoogle ScholarPubMed
Silove, D., Tarn, R., Bowles, R., & Reid, J. (1991). Psychosocial needs of torture survivors. Australian and New Zealand Journal of Psychiatry, 25(4), 481–490. doi: 10.3109/00048679109064441CrossRefGoogle ScholarPubMed
Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R. A., & van Ommeren, M. (2009, Aug 5). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: A systematic review and meta-analysis. Journal of the American Medical Association, 302(5), 537–549. doi:302/5/537 [pii] 10.1001/jama.2009.1132CrossRefGoogle Scholar
Steel, Z., Silove, D., Bird, K., McGorry, P., & Mohan, P. (1999). Pathways from war trauma to posttraumatic stress symptoms among Tamil asylum seekers, refugees and immigrants. Journal of Traumatic Stress, 12, 421–435. doi:10.1023/A:1024710902534CrossRefGoogle ScholarPubMed
Stein, N. R., Mills, M. A., Arditte, K., Mendoza, C., Borah, A. M., Resick, P. A., … Consortium, S. S. (2012, Nov). A scheme for categorizing traumatic military events. Behavior Modification, 36(6), 787–807. doi:10.1177/0145445512446945CrossRefGoogle Scholar
Stotz, S. J., Elbert, T., Muller, V., & Schauer, M. (2015). The relationship between trauma, shame, and guilt: Findings from a community-based study of refugee minors in Germany. European Journal of Psychotraumatology, 6, 25863. doi:10.3402/ejpt.v6.25863CrossRefGoogle ScholarPubMed
UNHCR (1951, 1967). Convention and Protocol Relating to the Status of Refugees.Google Scholar
UNHCR (2020). Figures at a glance. Retrieved from https://www.unhcr.org/ph/figures-at-a-glance.Google Scholar
Wiedemann, M., Stott, R., Nickless, A., Beierl, E. T., Wild, J., Warnock-Parkes, E., … Ehlers, A. (2020). Cognitive processes associated with sudden gains in cognitive therapy for posttraumatic stress disorder in routine care. Journal of Consulting and Clinical Psychology, 88, 455–459. doi:10.1037/ccp0000488.CrossRefGoogle ScholarPubMed
Young, H. P. (2015). The evolution of social norms. Annual Review of Economics, 7, 359–387.CrossRefGoogle Scholar
Zalta, A. K., & Held, P. (2020). Commentary on the special issue on moral injury: Leveraging existing constructs to test the heuristic model of moral injury. Journal of Traumatic Stress, 33, 598–599. doi:10.1002/jts.22516.CrossRefGoogle ScholarPubMed
Zerach, G., & Levi-Belz, Y. (2018). Moral injury process and its psychological consequences among Israeli combat veterans. Journal of Clinical Psychology, 74(9), 1526–1544. doi:10.1002/jclp.22598CrossRefGoogle ScholarPubMed
Supplementary material: File

Nickerson et al. supplementary material

Tables A-B

Download Nickerson et al. supplementary material(File)
File 19.4 KB