A narrative thematic analysis of moral injury in combat veterans

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).

The article is here.

Dear Donald Trump: I treat combat veterans with PTSD, and they are not weak

Joan Cook
The Conversation
Originally published October 5, 2016

Here is an excerpt:

Combat trauma is a powerful predictor for a number of mental health problems. PTSD is, of course, the most notable consequence, but veterans who have served in war zones also suffer alarming rates of depression, anxiety and substance abuse. And in recent years, the high suicide rates among U.S. service members have soared to an estimated 22 dying by their own hand each day.

If knowing that isn’t enough to make most Americans – including you – hang their heads, pause in appreciation and potentially cry, I’m not sure what would.

Sadly, veterans with PTSD also have what health care professionals call a “reduced quality of life.” They go to work less and use more health care services.

Unless treated, PTSD typically runs a chronic course and haunts a person for many years or decades. Thus, the substantial burden of PTSD is not just on a veteran’s back, but on their families, their communities and society as well.

The article is here.

A Review of Research on Moral Injury in Combat Veterans

Sheila Frankfurt and Patricia Frazier
Military Psychology
http://dx.doi.org/10.1037/mil0000132

Abstract


The moral injury construct has been proposed to describe the suffering some veterans experience when they engage in acts during combat that violate their beliefs about their own goodness or the goodness of the world. These experiences are labeled transgressive acts to identify them as potentially traumatic experiences distinct from the fear-based traumas associated with posttraumatic stress disorder. The goal of this article was to review empirical and clinical data relevant to transgressive acts and moral injury, to identify gaps in the literature, and to encourage future research and interventions. We reviewed literature on 3 broad arms of the moral injury model proposed by Litz and colleagues (2009): (a) the definition, prevalence, and potential correlates of transgressive acts (e.g., military training and leadership, combat exposure, and personality), (b) the relations between transgressive acts and the moral injury syndrome (e.g., self-handicapping, self-injury, demoralization), and (c) some of the proposed mechanisms of moral injury genesis (e.g., shame, guilt, social withdrawal, and self-condemnation). We conclude with recommendations for future research for veterans suffering with moral injury.


Combat can require individuals to violate their consciences repeatedly. For several decades, clinicians have noted the psychological impact on veterans of engaging in killing, committing atrocities, and violating the rules of engagement (Haley, 1974). Despite this clinical attention, most psychological research on veterans' war wounds has focused on post traumatic stress disorder (PTSD; American Psychiatric Association, 2013), a fear-based disorder that results from exposure to life-threatening events, rather than on the consequences of active participation in warfare.

The moral injury syndrome was proposed to describe the constellation of shame and guilt based disturbances that some combat veterans experience after engaging in wartime acts of commission (e.g., killing) or omission (e.g., failing to prevent atrocities; Litz et al., 2009). The moral injury syndrome was proposed to be constituted of the PTSD symptoms of intrusive memories, emotional numbing, and avoidance, along with collateral effects such as self-injury, demoralization, and self-handicapping (Litz et al., 2009).

The article is here.