Moral Injury and Its Impact on Veterans

   An important aspect of veterans' mental health is moral injury (MI) and its impact. A moral injury can occur in response to acting or witnessing behaviors that go against an individual's values and moral beliefs. In traumatic situations, people may perpetrate, fail to prevent, or witness events that contradict deeply held moral beliefs and expectations (Norman & Maguen, 2021). Of veterans, over half have experienced moral injuries (Koenig et al., 2019). It’s often associated with a comorbidity of mental health issues such as suicide ideation and post-traumatic stress disorder (PTSD). 

   Research has shown that moral injury is common among veterans with PTSD (Currier et al., 2019). Moral injury can accompany feelings of guilt, shame, self-condemnation, loss of trust, loss of meaning, and spiritual struggles. Veterans who experience PTSD symptoms might struggle with co-occurring cognitive, emotional, and behavioral conflicts that may have been caused by moral injuries. For some individuals, transgressing cherished moral values or experiencing betrayal by trusted others in high-stakes situations may be severely traumatic (Koenig et al., 2019). The identification and treatment of MI among those with PTSD may help in the management of symptoms.

   Recent research suggests that exposure to potentially morally injurious experiences may be associated with an increased risk for suicidal behavior among US combat veterans. Data from survey results were analyzed and showed that depression and PTSD were strong correlators of suicide ideation and attempts among those who experienced moral injury (Nichter et al., 2021). The events in combat and other missions may violate one’s deeply held belief systems and, for some service members, may result in inner conflict. Exposure to wartime atrocities and combat-related guilt has been shown to predict increased suicidal ideation (Bravo et al., 2020). To better inform prevention and treatment efforts among veterans, it’s important to identify risk factors that may moderate associations between moral injury and suicidal behavior. 

   Moral injury can be self-directed or other-directed. The two categories are defined by the attribution of responsibility for the event: personal responsibility (veteran's reported distress is related to his own behavior) versus responsibility of others (veteran's distress is related to actions taken by others) (Schorr et al., 2018). In one study, self-compassion was found to combat feelings of overidentification, or a tendency to overidentify with one’s failings and shortcomings that resulted after self-directed moral injury. Mindfulness and social connectedness also were found to weaken the impact of other-directed moral injury (Kelley et al., 2019). Prayer and meditation teach individuals to bring awareness to the present moment, with a sense of nonjudgment and acceptance of current thoughts, emotions, and sensations. These may be variables that mental health professionals should consider when working with veterans who have experienced moral injuries.

   Some resources on moral injury include:

• Moral Injury Support by VOA
• Center for Post Traumatic Growth
• International Society for Traumatic Stress Studies
• Moral Injury article by VA PTSD website
• Moral Injury in Health Care Workers article by VA PTSD
• The Moral Injury Project at Syracuse University
• Moral Injury Support Network for Servicewomen, Inc.
• Wounded Warrior Project Mental Health Services
• VA Mental Health Services

   References

• Currier, J. M., McDermott, R. C., Farnsworth, J. K., & Borges, L. M. (2019). Temporal associations between moral injury and posttraumatic stress disorder symptom clusters in military veterans. Journal of Traumatic Stress, 32(3), 382–392. https://doi.org/10.1002/jts.22367 
• Kelley, M. L., Bravo, A. J., Davies, R. L., Hamrick, H. C., Vinci, C., & Redman, J. C. (2019). Moral injury and suicidality among combat-wounded veterans: The moderating effects of social connectedness and self-compassion. Psychological Trauma: Theory, Research, Practice, and Policy, 11(6), 621–629. https://doi.org/10.1037/tra0000447 
• ​Koenig, H. G., Youssef, N. A., & Pearce, M. (2019). Assessment of moral injury in veterans and active duty military personnel with PTSD: A Review. Frontiers in Psychiatry, 10. https://doi.org/10.3389/fpsyt.2019.00443 
• Nichter, B., Norman, S. B., Maguen, S., & Pietrzak, R. H. (2021). Moral injury and suicidal behavior among us combat veterans: Results from the 2019–2020 national health and resilience in veterans study. Depression and Anxiety, 38(6), 606–614. https://doi.org/10.1002/da.23145 
• Norman, S. B., & Maguen, S. (2020, April 20). Moral Injury. U.S. Department of Veterans Affairs. Retrieved from https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp 
• Schorr, Y., Stein, N. R., Maguen, S., Barnes, J. B., Bosch, J., & Litz, B. T. (2018). Sources of moral injury among war veterans: A qualitative evaluation. Journal of Clinical Psychology, 74(12), 2203–2218. https://doi.org/10.1002/jclp.22660