Moral injury in Dutch treatment-seeking veterans: a latent profile analysis

Abstract

ABSTRACT Background: Moral injury (MI) is a construct distinct from, yet related to, post-traumatic stress disorder (PTSD). To date, no study has assessed MI among Dutch treatment-seeking veterans using a validated measure. Objective: This study aimed to (a) examine the factor structure and psychometric properties of the Dutch Expressions of Moral Injury Scale – Military Version (EMIS-M); (b) to identify profiles of PTSD and MI outcomes among treatment-seeking Dutch veterans, as well as their associations with comorbid psychopathology and family functioning. Method: Participants were 455 Dutch treatment-seeking veterans at four national psychotrauma centres. Data were drawn from pre-intake routine outcome monitoring assessments. We evaluated the internal consistency, temporal stability, and factor structure of the EMIS-M, and conducted latent profile analysis (LPA) to identify PTSD and MI profiles, followed by analyses of associated psychopathology and family functioning. Results: The EMIS-M demonstrated acceptable psychometric properties. Confirmatory factor analysis (CFA) supported a two-factor structure (MI-self and MI-other), though fit indices suggested room for improvement. LPA revealed three profiles: ‘Subclinical MI and PTSD’ (n = 95, 20.9%), ‘Moderate MI and PTSD’ (n = 218, 47.9%), and ‘High MI and PTSD’ (n = 142, 31.2%). Higher levels of MI and PTSD were associated with greater comorbid psychopathology. Family functioning was significantly poorer in the Moderate and High profiles compared to the Subclinical profile. Conclusions: Findings indicate that the Dutch EMIS-M is a psychometrically acceptable instrument for assessing MI among treatment-seeking veterans. MI frequently co-occurred with PTSD and was associated with greater psychopathology and poorer family functioning, underscoring the need for careful assessment of MI in veteran care.