Moral injury in military families

Frontiers in Psychiatry, 2022

The impact of “moral injury” (MI) among deployed veterans, defined as actions in combat that violate a veteran's moral beliefs and result in psychological distress, has increasingly become a significant clinical concern separate from other trauma- and stressor-related disorders. MI involves severe distress over violations of core beliefs often followed by feelings of guilt and conflict and is common among veterans with PTSD. While the psychological impact of PTSD is well-documented among veterans, this has been done less so with respect to MI. We studied MI among 1,032 deployed veterans who were outpatients in a large non-profit multi-hospital system in central Pennsylvania. The study included active duty and Guard/Reserve members, as well as veterans who were not Department of Veterans Affairs (VA) service users. Our hypothesis was that, controlling for other risk factors, veterans with high MI would have current mental disorders. Our secondary hypothesis was that MI would be a...

The term moral injury has been coined to describe the suffering that may develop following a violation of deeply held moral beliefs and values and subsequent difficulties in functioning. Yet despite an increase in research and intervention approaches for this topic, the relationship between moral injury and mental health diagnoses such as Posttraumatic Stress Disorder (PTSD) remains unclear and concern exists that, in some cases, moral injury might be used to unnecessarily pathologize moral processes. With the goal of further refining the construct, we argue that moral injury is a condition distinct from PTSD and other disorders and, using a functional approach, propose enhanced definitions for the terms, morally injurious event, moral pain, moral injury, and moral healing. Consistent with these new definitions, we then argue for Acceptance and Commitment Therapy (ACT) as a feasible and promising treatment for moral injury and present initial qualitative data supporting the intervention.

Moral injury, a term coined to represent the potential negative outcomes following transgression of deeply held moral values and beliefs, has recently gained increased recognition as a major concern among military service members exposed to trauma. However, working definitions of moral injury have not yet fully clarified the mechanisms whereby violations of conscience result in these outcomes or their co-occurrence with posttraumatic stress disorder (PTSD). In this paper, advances from the field of moral psychology are used to integrate cognitive, affective, and social dimensions of the emerging moral injury construct, while also pointing to new possibilities for clinical intervention. After reviewing the salience of moral injury for military and veteran populations, the presence of negative moral emotions (e.g., guilt, anger, disgust) are examined within the context of trauma and military-related PTSD. Next, social functionalist accounts of moral emotions are used to explain the development of moral injury and are linked to potential etiologies of PTSD that emphasize both fear and nonfear emotions. Finally, the clinical importance of positive moral emotions for existing and emerging trauma-focused interventions is discussed. Future directions for research and clinical interventions are identified highlighting the importance of utilizing community support.

Journal of Military, Veteran and Family Health

While Post Traumatic Stress Disorder (PTSD) has garnered much research attention, the concept of moral injury has recently been increasingly raised. This scoping review was undertaken to explored how the literature conceptualizes the relation between PTSD and moral injury. Moral injury Posttraumatic Stress Disorder "…the emotional and spiritual impact of participating "a history of exposures to a traumatic event that in, witnessing, and/or being victimized by actions and produces symptoms that can be found in the four behaviors which violate a service member's core moral symptom clusters that include intrusion, avoidance, values and behavioral expectations of self or others. negative alterations in cognitions and mood, and Moral injury almost always pivots with the dimension alterations in arousal and reactivity" of time: moral codes evolve alongside identities, and (American Psychological Association, 2013) transitions inform perspectives that form new conclusions about old events."

Communicating Mental Health, 2020

Recent international military engagements have inspired scholars and clinicians to consider the psychological impacts of military service. Increasing numbers of soldiers are returning from deployments in Iraq or Afghanistan. This has particularly re-ignited interest in the psychological impacts of military service. In this chapter, we discuss the challenges of understanding and communicating about a new concept of traumatic stress: moral injury. Combat imposes many impairments to mental health, but warriors, scholars, and communities realize these challenges are nothing new. Surviving veterans of wars in Korea and Vietnam sometimes disclose hidden burdens that echo narratives about warriors in the Iliad . Letters and diaries from soldiers in the US Civil War confirm that war changes combatants . War changes warriors even in campaigns featuring considerable public support . For example, Beebe and Appel (1958) observed: During World War II infantrymen were breaking down psychologically at such high rates in certain combat areas as to suggest to many psychiatric observers that the resistance of the average man was being exceeded, that the stress of warfare in these areas was so MORAL INJURY 2 great that most men exposed to it long enough would break down. Such studies as could be made in wartime seemed to confirm these impressions (p.1). Increases in combat-related stressors sometimes provide a context for acute and chronic psychophysical breakdown (see that can last well into later life post-deployment (Kang, Aldwin, Choun, & Spiro III., 2016). Despite the rewards of serving one's country, soldiers must often grapple with guilt, shame, resentment, and disorientation associated with combat-related violence. In turn, soldiers may lose confidence in the significance of morality and their sense of self. They may lose the ability to trust themselves and others. Important work has targeted the physical and mental health problems associated with the experience of combat. Recent empirical efforts have expanded the understanding of combat-related trauma. For instance, scholars have considered the health effects from cumulative exposure to war stress, examined previously classified reports on frontline psychiatry, investigated the prevalence and treatment of mental health conditions among deployed personnel, and proposed clinical models of risk and protective factors contributing to combat-related post-traumatic stress disorder (PTSD) (e,g, Battles et al., 2018; Litz et al., 2016;. However, dominant clinical models do not fully capture certain forms of combat trauma and how individuals communicate about their experiences. Recent communication research provides some important insights about the dynamics of reintegration with spouses and families (e.g., ). Yet there is still much to learn about the post-deployment experiences of veterans and how they cope with life post-deployment. There

Frontiers in Psychiatry, 2018

Objective: Moral injury may result from perpetration-based and betrayal-based acts that violate deeply held norms; however, researchers and clinicians have little guidance about the moral injury syndrome's specific developmental pathways following morally injurious events. The present study's objective was to examine the direct and indirect pathways proposed in a frequently cited model of moral injury (1) in relation to two types of military-related traumas [experiencing military sexual trauma (MST) and combat exposure]. Methods: Secondary analyses were conducted within a sample of post-9/11 veterans at a Southwestern Veterans Health Care System (N = 310) across two time-points. Structural equation modeling tested the direct and indirect pathways from MST and combat to a PTSD-depression factor via betrayal, perpetration, guilt, and shame. Results: Betrayal accounted for the association between MST and PTSD-depression (β = 0.10, p < 0.01, 95% CI = 0.01 − 0.11) and perpetration accounted for the association between combat and PTSD-depression (β = 0.07, p < 0.05, 95% CI = 0.02 − 0.14). The indirect path from combat to shame to PTSD-depression was significant (β = 0.16, p < 0.01, 95% CI = 0.07 − 0.28) but the path through guilt was not. The specific indirect paths through perpetration or betrayal to shame or guilt were non-significant. Conclusions: Betrayal and perpetration are associated with PTSD-depression following MST and combat. Results suggest multiple pathways of moral injury development following different military traumas and morally injurious events. Implications for moral injury conceptualization and treatment are discussed.

Reflective Practice Formation and Supervision in Ministry, 2008

The moral dimension of combat trauma is being increasingly recognised within psychological and philosophical literature. Indeed, there is a growing movement to distinguish between PTSD and “moral injury.” By moral injury, these theorists refer to something like what psychiatrist Jonathan Shay describes as “the soul wound inflicted by doing something that violates one’s own ethics, ideals, or attachments.” This type of injury does not appear to be captured by the increasing diagnosis of Posttraumatic Stress Disorder (PTSD). Each of these has important moral implications for philosophers of war, but the conditions need to be appropriately delineated before appropriate remedies can be identified. The growing interest in moral injury opens the door for philosophers to explore and explain how moral concepts can contribute to understanding, treatment and prevention of combat trauma-related psychological injuries. In this paper I will explore some of the significant differences between PTSD and moral injury, and how these differences hold moral significance. Using the clinical guidelines presented in the DSM-5, I will explore how the conditions of PTSD differ in terms of clinical presentation. I will then consider the experiential differences between moral injury and PTSD, which will reveal some possible avenues for therapeutic interventions for the morally injured.

Journal of Traumatic Stress, 2020

Military service often requires engaging in activities, witnessing acts, or immediate decision‐making that may violate the moral codes and personal values to which most individuals ascribe. If unacknowledged, these factors can lead to injuries that can affect the physical, psychological, social, and spiritual health of military men and women. The term moral injury has been assigned to these soul‐ceasing experiences. Although researchers have attempted to define moral injury and what leads to such experiences, inconsistencies across definitions exist. In addition, nearly all existing definitions have lacked empirical support. The purpose of the present systematic review was to explore how moral injury has been defined in research with military populations, using Cooper&#39;s approach to research synthesis as well as PRISMA guidelines. An in‐depth review of 124 articles yielded 12 key definitions of moral injury across the literature. Two of these 12 definitions were grounded in empir...

Traumatology, 2011

It is widely recognized that, along with physical and psychological injuries, war profoundly affects veterans spiritually and morally. However, research about the link between combat and changes in morality and spirituality is lacking. Moral injury is a construct that we have proposed to describe disruption in an individual's sense of personal morality and capacity to behave in a just manner. As a first step in construct validation, we asked a diverse group of health and religious professionals with many years of service to active duty warriors and veterans to provide commentary about moral injury. Respondents were given a semistructured interview and their responses were sorted. The transcripts were used to clarify the range of potentially and morally injurious experiences in war and the lasting sequelae of these experiences. There was strong support for the usefulness of the moral injury concept; however, respondents chiefly found our working definition to be inadequate.