Veterans Must Also Heal From Moral Injury After War

Camillo Mac Bica
truthout.org
Originally published Nov 11, 2019

Here are two excerpts:

Humankind has identified and internalized a set of values and norms through which we define ourselves as persons, structure our world and render our relationship to it — and to other human beings — comprehensible. These values and norms provide the parameters of our being: our moral identity. Consequently, we now have the need and the means to weigh concrete situations to determine acceptable (right) and unacceptable (wrong) behavior.

Whether an individual chooses to act rightly or wrongly, according to or in violation of her moral identity, will affect whether she perceives herself as true to her personal convictions and to others in the moral community who share her values and ideals. As the moral gravity of one’s actions and experiences on the battlefield becomes apparent, a warrior may suffer profound moral confusion and distress at having transgressed her moral foundations, her moral identity.

Guilt is, simply speaking, the awareness of having transgressed one’s moral convictions and the anxiety precipitated by a perceived breakdown of one’s ethical cohesion — one’s integrity — and an alienation from the moral community. Shame is the loss of self-esteem consequent to a failure to live up to personal and communal expectations.

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Having completed the necessary philosophical and psychological groundwork, veterans can now begin the very difficult task of confronting the experience. That is, of remembering, reassessing and morally reevaluating their responsibility and culpability for their perceived transgressions on the battlefield.

Reassessing their behavior in combat within the parameters of their increased philosophical and psychological awareness, veterans realize that the programming to which they were subjected and the experience of war as a survival situation are causally connected to those specific battlefield incidents and behaviors, theirs and/or others’, that weigh heavily on their consciences — their moral injury. As a consequence, they understand these influences as extenuating circumstances.

Finally, as they morally reevaluate their actions in war, they see these incidents and behaviors in combat not as justifiable, but as understandable, perhaps even excusable, and their culpability mitigated by the fact that those who determined policy, sent them to war, issued the orders, and allowed the war to occur and/or to continue unchallenged must share responsibility for the crimes and horror that inevitably characterize war.

The info is here.

The Moral Injury of Pardoning War Crimes

The Editorial Board
The New York Times
Originally posted 22 Nov 19

Here is an excerpt:

That Mr. Trump would pardon men accused or convicted of war crimes should come as little surprise, given that he campaigned on promises to torture the nation’s enemies and kill their families. Mr. Trump in May became the first modern president to pardon a person convicted of war crimes, when he pardoned Michael Behenna, a former Army lieutenant, who had been convicted of killing a prisoner in Iraq.

The president may think he’s supporting men and women in uniform. “When our soldiers have to fight for our country, I want to give them the confidence to fight,” he said in a statement issued by the White House. “We train our boys to be killing machines, then prosecute them when they kill!” he said on Twitter last month.

Whatever the reason, absolving people who commit war crimes does great harm to society in general, and the men and women who served honorably — as far more than “killing machines” — in the wars since the Sept. 11 terrorist attacks in particular.

A nation has to know that military action being taken in its name follows morally defensible rules — that soldiers do not, for instance, kill unarmed civilians or prisoners.

To excuse men who have so flagrantly violated those rules — to treat them as heroes, even — is to cast the idea of just war to the winds. It puts the nation and veterans at risk of moral injury, the shattering of a moral compass.

One of the loudest groups pushing for Mr. Trump’s pardons was United American Patriots, a nonprofit organization that supports numerous soldiers accused of crimes, including Mr. Lorance, Mr. Behenna and Major Golsteyn. Last month, Chief Gallagher sued two of his former lawyers and United American Patriots, alleging that his lawyers tried to delay the case to increase fund-raising for the organization.

Supporters of the pardoned men say the military justice system comes down too hard and too often on honorable soldiers fighting through the fog of war. That wouldn’t explain why United American Patriots has made a cause célèbre of Robert Bales, who pleaded guilty to slaughtering 16 Afghan civilians in their homes during a one-man nighttime rampage in 2012.

The info is here.

Suicide Has Been Deadlier Than Combat for the Military

Carol Giacomo
The New York Times
Originally published November 1, 2019

Here are two excerpts:

The data for veterans is also alarming.

In 2016, veterans were one and a half times more likely to kill themselves than people who hadn’t served in the military, according to the House Committee on Oversight and Reform.

Among those ages 18 to 34, the rate went up nearly 80 percent from 2005 to 2016.

The risk nearly doubles in the first year after a veteran leaves active duty, experts say.

The Pentagon this year also reported on military families, estimating that in 2017 there were 186 suicide deaths among military spouses and dependents.

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Experts say suicides are complex, resulting from many factors, notably impulsive decisions with little warning. Pentagon officials say a majority of service members who die by suicide do not have mental illness. While combat is undoubtedly high stress, there are conflicting views on whether deployments increase risk.

Where there seems to be consensus is that high-quality health care and keeping weapons out of the hands of people in distress can make a positive difference.

Studies show that the Department of Veterans Affairs provides high-quality care, and its Veterans Crisis Line “surpasses most crisis lines” operating today, according to Terri Tanielian, a researcher with the RAND Corporation. (The Veterans Crisis Line is staffed 24/7 at 800-273-8255, press 1. Services also are available online or by texting 838255.)

But Veterans Affairs often can’t accommodate all those needing help, resulting in patients being sent to community-based mental health professionals who lack the training to deal with service members.

The info is here.

Are We Causing Moral Injury to Our Physician Workforce?

Carolyn Meltzer
theneuroethicsblog.com
Originally posted November 5, 2019

Here is an excerpt:

The term moral injury was coined by psychiatrist Jonathan Shay, MD PhD, who, while working at a Veterans Affairs hospital, noted that moral injury is present when 1) there is a betrayal of what is considered morally correct, 2) by someone who holds legitimate authority (conceptualized by Shay as “leadership malpractice”), and 3) in a high-stakes situation (Shay and Monroe 1998). Nash and Little (2013) went on to propose a model that identified the types of war-zone events that contributed to moral injury as witnessing events that are morally wrong (or strongly contradicted one’s own moral code), acting in ways that violate moral values, or feeling betrayed by those who were once trusted. In a fascinating study using the Moral Injury Event Scale and resting-state functional magnetic resonance imaging (fMRI), Sun and colleagues (2019) were able to discern a distinct pattern of altered functional neural connectivity in soldiers exposed to morally injurious events. In fact, functional connectivity between the left inferior parietal lobule and bilateral precuneus was positively related with the soldiers’ post-traumatic stress disorder (PTSD) symptoms and negatively related with scores on the Moral Injury Event Scale.

Moral injury has been recently applied as a construct for physician burnout. Those who argue for this framework propose that structural and cultural factors have contributed to physician burden by undervaluing physicians and over-relying on financial metrics (such as relative value units, RVUs) as the primary surrogate of physician productivity (Nurok and Gewertz 2019). Turner (2019) recently compared the military experience to that of physician providers. While one may draw similarities between the front line of healthcare delivery and that experienced by soldiers, Turner argues that a fundamental tenet of military leadership - that leaders eat last – provides effective support for the health of the workforce. In increasingly large healthcare organizations managed by administrators who may be distant from the front line and reliant on metrics of productivity, the necessary sense of empathy and support from leadership can seem lacking.

The info is here.

Moral Decision Making, Religious Strain, and the Experience of Moral Injury

Steven Lancaster and Maggie Miller
PsyArXiv Preprints

Abstract

Moral injury is the recognition that acts perpetrated during combat, or other stressful situations, can having lasting psychological impacts. Models of moral injury examine the role of transgressive acts, moral appraisals of these acts, and the symptoms of moral injury. However, little research has examined potential pathways between these elements. The current study examined everyday moral decision making and aspects of religious functioning as possible mediators of these relationships in a military veteran sample. Our pre-registered structural equation model supported a relationship between acts and appraisals; however, this relationship was not mediated by moral decision making as we had hypothesized. Our results demonstrated that religious strain significantly mediated the relationship between moral appraisals and both self- and other-directed symptoms of moral injury. Additional research is needed to better understand how and which transgressive acts are appraised as morally wrong. Further research is also needed to better integrate moral decision making into our understanding of moral injury.

From the Discussion:

Contrary to our predictions, moral decision making did not mediate the relationship between acts and appraisals in our hypothesized model.  This is surprising due to moral conflict being seen as the core of moral injury experience (Jinkerson, 2016).  Given the importance of moral evaluations of one’s actions in moral injury, we expected that one’s “moral compass would make a significant contribution to this model (Drescher & Foy, 2008, p. 99).  It is not clear whether this null finding is due to the method in which moral decision making was assessed or if perhaps moral decision making for everyday experiences (or non-combat experiences) fails to play a role in how one evaluates their potentially transgressive experiences (Christensen & Gomila, 2012).  The EDMD is limited in at least two ways which may have affected our results.  First, the test lacks a contemplation component which is necessary for the psychological processing of an moral decision (Gunia, Wang, Huang, Wang, & Murnighan, 2012).  Second, given that the EDMD focuses on everyday experiences, it may be limited in its ability to assess the moral decisions made during stressful situations (Yousef et al., 2012).  While moral decision making did not mediate as the act-appraisal relationship as hypothesized, it was correlated with other-directed symptoms of moral injury and the MODINDICES output in MPLUS indicated this pathway would improve model fit.  While not hypothesized, one reason for this finding could be that higher altruism leads an individual to give the “benefit of the doubt” to others, particularly those with whom they have endured stressful or traumatic experiences (Staub & Vollhardt, 2008).  Given the relatively young status of the field, additional research is needed to better understand who experiences these acts as negative/wrong and for which types of events does this occur.  Future studies may want to incorporate a broad range of potential mediators including multiple indices of moral decision making.

The pre-print is here.

Not “burnout,” not moral injury—human rights violations

Pamela Wible
www.idealcare.org
Originally posted March 18, 2019

Here is an excerpt:

Moral injury now extends beyond combat veterans to include physicians in 2018 when Dean and Talbot announced their opposition and alternative to the label physician “burnout.” They believe (as I do) that physician cynicism, exhaustion, and decreased productivity are symptoms of a broken system. Economic forces, technological demands, and widespread intergenerational physician mental health wounds have culminated in a highly dysfunctional and toxic health care system in which we find ourselves in daily forced betrayal of our deepest values.

Manifestations of moral injury in victims include self-harm, poor self-care, substance abuse, recklessness, self-defeating behaviors, hopelessness, self-loathing, and decreased empathy. I’ve witnessed all far too frequently among physicians.

Yet moral injury is not an official diagnosis. No specific solutions are offered at medical institutions to combat physician moral injury though moral injury treatment among military may include listening circles (where veterans share battlefield stories), forgiveness rituals, and individual therapy. The fact is most victims of moral injury struggle on their own.

With no evidence-based treatments for physician moral injury and zero progress after forty years of burnout prevention, what next? Enter the real diagnosis—human rights violations—with clear evidence-based solutions.

The info is here.

Moral Injury in International Relations

Jelena Subotic & Brent J Steele
Journal of Global Security Studies
https://doi.org/10.1093/jogss/ogy021
Published: 28 August 2018

Abstract

The war in Iraq unleashed disastrous global instability—from the strengthening of Al-Qaeda, to the creation of ISIS, and civil war in Syria accompanied by a massive exodus of refugees. The war in Afghanistan is continuing in perpetuity, with no clear goals or objectives other than the United States’ commitment to its sunk cost. The so-called war on terror is a vague catch-all phrase for a military campaign against moving targets and goalposts, with no end date and no conceivable way to declare victory. The toll of these wars on civilians in Iraq and Afghanistan and elsewhere in the Middle East, on US troops, and on the US economy is staggering. But these ambiguous campaigns are also fundamentally changing US state identity—its view of itself, its role in the world, and its commitment to a liberal international order. They are producing profound anxiety in the US body politic and anxiety in US relationships with other international actors. To understand the sources and consequences of this anxiety, we adopt an ontological security perspective on state identity. We enrich ontological security scholarship by introducing the concept of moral injury and its three main consequences: loss of control, ethical anxiety, and relational harm. We demonstrate how the concept of moral injury illuminates some of the most central anxieties at the core of US identity, offering a new understanding of our global moment of crisis.

The info is here.

Who Is Experiencing What Kind of Moral Distress?

Carina Fourie
AMA J Ethics. 2017;19(6):578-584.

Abstract

Moral distress, according to Andrew Jameton’s highly influential definition, occurs when a nurse knows the morally correct action to take but is constrained in some way from taking this action. The definition of moral distress has been broadened, first, to include morally challenging situations that give rise to distress but which are not necessarily linked to nurses feeling constrained, such as those associated with moral uncertainty. Second, moral distress has been broadened so that it is not confined to the experiences of nurses. However, such a broadening of the concept does not mean that the kind of moral distress being experienced, or the role of the person experiencing it, is morally irrelevant. I argue that differentiating between categories of distress—e.g., constraint and uncertainty—and between groups of health professionals who might experience moral distress is potentially morally relevant and should influence the analysis, measurement, and amelioration of moral distress in the clinic.

The info is here.

Physicians aren’t ‘burning out.’ They’re suffering from moral injury

Simon G. Talbot and Wendy Dean
STAT News
Originally published July 26, 2018

Here is an excerpt:

The term “moral injury” was first used to describe soldiers’ responses to their actions in war. It represents “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Journalist Diane Silver describes it as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”

The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.

Most physicians enter medicine following a calling rather than a career path. They go into the field with a desire to help people. Many approach it with almost religious zeal, enduring lost sleep, lost years of young adulthood, huge opportunity costs, family strain, financial instability, disregard for personal health, and a multitude of other challenges. Each hurdle offers a lesson in endurance in the service of one’s goal which, starting in the third year of medical school, is sharply focused on ensuring the best care for one’s patients. Failing to consistently meet patients’ needs has a profound impact on physician wellbeing — this is the crux of consequent moral injury.

The information is here.

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.

Moral Injury and Religiosity in US Veterans With Posttraumatic Stress Disorder Symptoms

Harold Koenig and others
The Journal of Nervous and Mental Disease: February 28, 2018

Abstract

Moral injury (MI) involves feelings of shame, grief, meaninglessness, and remorse from having violated core moral beliefs related to traumatic experiences. This multisite cross-sectional study examined the association between religious involvement (RI) and MI symptoms, mediators of the relationship, and the modifying effects of posttraumatic stress disorder (PTSD) severity in 373 US veterans with PTSD symptoms who served in a combat theater. Assessed were demographic, military, religious, physical, social, behavioral, and psychological characteristics using standard measures of RI, MI symptoms, PTSD, depression, and anxiety. MI was widespread, with over 90% reporting high levels of at least one MI symptom and the majority reporting at least five symptoms or more. In the overall sample, religiosity was inversely related to MI in bivariate analyses (r = −0.25, p < 0.0001) and multivariate analyses (B = −0.40, p = 0.001); however, this relationship was present only among veterans with severe PTSD (B = −0.65, p = 0.0003). These findings have relevance for the care of veterans with PTSD.

The paper is here.

What is moral injury, and how does it affect journalists covering bad stuff?

Thomas Ricks
Foreign Policy
Originally published September 5, 2017

Here is an excerpt:

They noted that moral injury is the damage done to a “person’s conscience or moral compass by perpetrating, witnessing, or failing to prevent acts that transgress personal moral and ethical values or codes of conduct.”

While not all journalists were affected the same way, the most common reactions were feelings of guilt at not having done enough personally to help refugees and shame at the behavior of others, such as local authorities, they wrote.

Journalists with children had more moral injury-related distress while those working alone said they were more likely to have acted in ways that violated their own moral code. Those who said they had not received enough support from their organization were more likely to admit seeing things they perceived as morally wrong. Less control over resources to report on the crisis also correlated significantly with moral injury. And moral injury scores correlated significantly with guilt. Greater guilt, in turn, was noted by journalists covering the story close to home and by those who had assisted refugees, the report added.

Feinstein and Storm wrote that moral injury can cause “considerable emotional upset.” They noted that journalists reported symptoms of intrusion. While they didn’t go into detail, intrusion can mean flashbacks, nightmares and unwanted memories. These can disrupt normal functioning. In my view, guilt and shame can also be debilitating.

The article is here.

Moral Injury, Posttraumatic Stress Disorder, and Suicidal Behavior Among National Guard Personnel.

Craig Bryan, Anna Belle Bryan, Erika Roberge, Feea Leifker, & David Rozek
Psychological Trauma: Theory, Research, Practice, and Policy 

Abstract

To empirically examine similarities and differences in the signs and symptoms of posttraumatic stress disorder (PTSD) and moral injury and to determine if the combination of these 2 constructs is associated with increased risk for suicidal thoughts and behaviors in a sample of U.S. National Guard personnel. Method: 930 National Guard personnel from the states of Utah and Idaho completed an anonymous online survey. Exploratory structural equation modeling (ESEM) was used to test a measurement model of PTSD and moral injury. A structural model was next constructed to test the interactive effects of PTSD and moral injury on history of suicide ideation and attempts. Results: Results of the ESEM confirmed that PTSD and moral injury were distinct constructs characterized by unique symptoms, although depressed mood loaded onto both PTSD and moral injury. The interaction of PTSD and moral injury was associated with significantly increased risk for suicide ideation and attempts. A sensitivity analysis indicated the interaction remained a statistically significant predictor of suicide attempt even among the subgroup of participants with a history of suicide ideation. Conclusion: PTSD and moral injury represent separate constructs with unique signs and symptoms. The combination of PTSD and moral injury confers increased risk for suicidal thoughts and behaviors, and differentiates between military personnel who have attempted suicide and those who have only thought about suicide.

The article is here.

What is moral injury in veterans?

Holly Arrow and William Schumacher
The Conversation
Originally posted May 21, 2017

Here is an excerpt:

The moral conflict created by the violations of “what’s right” generates moral injury when the inability to reconcile wartime actions with a personal moral code creates lasting psychological consequences.

Psychiatrist Jonathan Shay, in his work with Vietnam veterans, defined moral injury as the psychological, social and physiological results of a betrayal of “what’s right” by an authority in a high-stakes situation. In “Achilles In Vietnam,” a book that examines the psychological devastation of war, a Vietnam veteran described a situation in which his commanding officers used tear gas on a village after the veteran and his unit had their gas masks rendered ineffective due to water damage. The veteran stated, “They gassed us almost to death.” This type of “friendly fire” incident is morally wounding in a way that attacks by an enemy are not.

Psychologist Brett Litz and his colleagues expanded this to include self-betrayal and identified “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” as the cause of moral injury.

Guilt and moral injury

A research study published in 1991 identified combat-related guilt as the best predictor of suicide attempts among a sample of Vietnam veterans with PTSD. Details of the veterans’ experiences connected that guilt to morally injurious events.

The article is here.

Moral injury in U.S. combat veterans: Results from the national health and resilience in veterans study

Blair E. Wisco Ph.D., Brian P. Marx Ph.D., Casey L. May B.S., Brenda Martini M.A., and others
Depression and Anxiety

Abstract

Background

Combat exposure is associated with increased risk of mental disorders and suicidality. Moral injury, or persistent effects of perpetrating or witnessing acts that violate one's moral code, may contribute to mental health problems following military service. The pervasiveness of potentially morally injurious events (PMIEs) among U.S. combat veterans, and what factors are associated with PMIEs in this population remains unknown.
Methods

Data were analyzed from the National Health and Resilience in Veterans Study (NHRVS), a contemporary and nationally representative survey of a population-based sample of U.S. veterans, including 564 combat veterans, collected September–October 2013. Types of PMIEs (transgressions by self, transgressions by others, and betrayal) were assessed using the Moral Injury Events Scale. Psychiatric and functional outcomes were assessed using established measures.
Results

A total of 10.8% of combat veterans acknowledged transgressions by self, 25.5% endorsed transgressions by others, and 25.5% endorsed betrayal. PMIEs were moderately positively associated with combat severity (β = .23, P < .001) and negatively associated with white race, college education, and higher income (βs = .11–.16, Ps < .05). Transgressions by self were associated with current mental disorders (OR = 1.65, P < .001) and suicidal ideation (OR = 1.67, P < .001); betrayal was associated with postdeployment suicide attempts (OR = 1.99, P < .05), even after conservative adjustment for covariates, including combat severity.
Conclusions

A significant minority of U.S combat veterans report PMIEs related to their military service. PMIEs are associated with risk for mental disorders and suicidality, even after adjustment for sociodemographic variables, trauma and combat exposure histories, and past psychiatric disorders.

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.

War Wounds That Time Alone Can't Heal

by Jane E. Brody
The New York Times
Originally published June 6, 2016

Here are two excerpts:
Therapists both within and outside the Department of Veterans Affairs increasingly recognize moral injury as the reason so many returning vets are self-destructive and are not helped, or only partly helped, by established treatments for PTSD.

Moral injury has some of the symptoms of PTSD, especially anger, depression, anxiety, nightmares, insomnia and self-medication with drugs or alcohol. And it may benefit from some of the same treatments. But moral injury has an added burden of guilt, grief, shame, regret, sorrow and alienation that requires a very different approach to reach the core of a sufferer’s psyche.

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Therapists who study and treat moral injury have found that no amount of medication can relieve the pain of trying to live with an unbearable moral burden. They say those suffering from moral injury contribute significantly to the horrific toll of suicide among returning vets — estimated as high as 18 to 22 a day in the United States, more than the number lost in combat.

The article is here.

Healing a Wounded Sense of Morality

Many veterans are suffering from a condition similar to, but distinct from, PTSD: moral injury, in which the ethical transgressions of war can leave service members traumatized.

By Maggie Puniewska
The Atlantic
Originally published July 3, 2015

Here are two excerpts:

Identifying moral injury can be tricky for two reasons: First, it’s easily mistaken for PTSD, which shares many of the same symptoms. And second, because veterans may feel too ashamed to talk about their moral infractions, therapists might not even know to look for the signs of moral injury at all, says Joseph Currier, an assistant professor of psychology at the University of South Alabama. To help therapists better understand how to diagnose the condition, he and several colleagues have developed a 20-item questionnaire that screens patients for moral injury, asking patients to rate their agreement with statements like “I did things in war that betrayed my personal values” and “I made mistakes in the war zone that led to injury and death.”

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But healing isn’t just confined to the individual. Emotions that guide morality, Currier explains, are rooted in social relationships:  “The function of guilt is to reconcile a potentially damaged social bond, whereas with shame, the reaction is to withdraw so the social group can preserve its identity,” he says.   For many veterans, therefore, recovery from moral injury depends in part on the civilian communities to which they return. “A part of feeling betrayed or distrusted or guilty by the practices of war is feeling alienated. It’s feeling like you can’t share your experiences because people will judge you or won’t understand,” Sherman says.

The entire article is here.

Healing Moral Wounds of War

Religion and Ethics News Weekly
PBS
Originally posted June 26, 2015

In her book Afterwar: Healing the Moral Wounds of Our Soldiers, Georgetown University philosophy professor Nancy Sherman argues that many of the 2.6 million U.S. service members returning from our wars in Afghanistan and Iraq suffer from complex moral injuries that are more than post-traumatic stress and that have to do with feelings of guilt, anger, and “the shame of falling short of your lofty military ideals.” Citizens have “a sacred obligation,” says Sherman, to morally engage with those who have fought in our name and who feel moral responsibility for traumatic incidents they experienced. Managing editor Kim Lawton interviews Sherman about the moral aftermath of war and visits a former Marine and his wife to talk about the healing that comes through listening, trust, hope, and moral understanding.