Prospective Associations Between Psychological Factors, Potentially Morally Injurious Events, and Psychiatric Symptoms Among Israeli Combatants: The Roles of Ethical Leadership and Ethical Preparation

Background: Exposure to potentially morally injurious events (PMIEs) during military service is known to be associated with psychiatric symptoms. However, antecedents and outcomes of exposure to PMIEs have only been studied in cross-sectional or retrospective-designed studies. In this prospective study, we examined associations between preenlistment characteristics, predeployment psychological factors, exposure to PMIEs, posttraumatic stress disorder (PTSD), and psychiatric symptoms, and the moderating roles of ethical leadership and ethical preparation, among combatants. Method: A sample of 335 active-duty Israeli combatants participated in a 2.5-year prospective study with three waves of measurements. Participants’ characteristics were assessed via semistructured interviews and validated self-report measures between 2019 and 2021. Results: Above and beyond preenlistment personal characteristics and psychiatric symptoms, predeployment psychological flexibility predicted higher levels of exposure to PMIEs-Other and Betrayal, and combat exposure predicted higher levels of exposure to PMIEs-Self, Other, and betrayal. Moreover, PMIEs-Betrayal predicted higher levels of PTSD and psychiatric symptoms, and ethical preparation predicted lower PTSD and psychiatric symptoms. Importantly, among combatants who reported high levels of ethical preparation and leadership, the association between exposure to PMIEs and PTSD and psychiatric symptoms following deployment dissolved. Conclusions: This is the first prospective study of antecedents and outcomes of exposure to PMIEs among active-duty combatants. Clinicians treating combatants should be aware of the putative role of psychological flexibility for exposure to PMIEs, as well as the promising mitigating role of ethical leadership and preparation for moral injury and psychopathological outcomes among combatants.