Held, P., Klassen, B. J., Hall, J. M., Friese, and others
Psychological Trauma: Theory, Research, Practice, and Policy.
Advance online publication. http://dx.doi.org/10.1037/tra0000364
Here is a portion of the Introduction:
In war, service members sometimes have to make difficult decisions, some of which may violate their deeply held beliefs and moral values. The term moral injury was coined to refer to the enduring mental health consequences that can occur from participating in, witnessing, or learning about acts that violate one’s moral code (Drescher et al., 2011; Litz et al., 2009; Shay, 1994). Some examples of potentially morally injurious events include disproportionate violence, engaging in atrocities, or violations of rules of engagement (Litz et al., 2009; Stein et al., 2012). Although consensus regarding how best to measure moral injury has not been reached, one preliminary estimate suggested that as many as 25% of a representative sample of veterans endorsed exposure to morally injurious experiences (Wisco et al., 2017). Involvement in these situations has been shown to be associated with a range of negative psychological reactions, including the development of mental health symptoms, such as posttraumatic stress disorder (PTSD), depression (Held, Klassen, Brennan, & Zalta, 2017; Maguen et al., 2010), substance use problems (Wilk et al., 2010) and suicidal ideation (Maguen et al., 2012).
Litz and colleagues (2009) have proposed the sole theoretical model of how moral transgressions result in the development of mental health symptoms. Following the morally injurious event, individuals experience a conflict between the event and their own moral beliefs. For example, a service member may believe that civilians should not be harmed during combat but is involved in an event that involves the death of noncombatants. In an attempt to resolve this cognitive conflict, self-directed attributions of the event’s cause may be made, such as service members believing that they were complicit in noncombatants being harmed. The stable, internal, and global attributions that result lead to the development of painful emotions (e.g., guilt, shame, fear of social rejection) and withdrawal from social interaction. Lack of social contact leads to missed opportunities for potentially corrective information and further strengthens the painful emotions and the stable, internal, and global attributions about the morally injurious event (e.g., Martin et al., 2017). It has been proposed that unless addressed, the moral injury continues to manifest and perpetuate itself through intrusions, avoidance, and numbing in a manner similar to PTSD (Jinkerson, 2016; Farnsworth, Drescher, Nieu- wsma, Walser, & Currier, 2014; Litz, Lebowitz, Gray, & Nash, 2016; Litz et al., 2009).
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