The Psychiatric Ramifications of Moral Injury Among Veterans

As former marine Timothy Kudo (1) puts it, “The ethical damage of war may be worse than the physical injuries we sustain …. To properly wage war, you have to recalibrate your moral compass …. Once you return from the battlefield, it is difficult or impossible to repair it.” Most soldiers are able to acutely compartmentalize and rationalize their experiences by their training, warrior culture, and, most importantly, through their military community (2). However, often it is when they separate from the military that the moral conflict surfaces; or, as Meager (3) describes in his book Killing from the Inside Out, they reach “moral clarity.”

Moral injury is not a new concept, but the term and clinical construct are relatively new because research in this field is still in its infancy. Acts of commission and omission called for by the active duty are often difficult to reconcile with one’s values in civilian life, causing internal distress and often moral injury (4). Psychiatrist Jonathan Shay (5) coined the term “moral injury” and defined it as a “betrayal of what is right by someone who holds legitimate authority in a high stakes situation.” The definition of moral injury has since been expanded to include “perpetrating, failing to prevent, bearing witness to acts that ultimately transgress one’s deeply held moral beliefs,” creating dissonance (2). Currier et al. (6) carried out a study with recently deployed veterans to better understand contextual factors in which moral injury occurs. Using semi-structured interviews, along with PTSD Checklist and Moral Injury Questionnaire-Military version, four main categories of morally injurious events were generated. These categories included organizational, environmental, cultural, and relational and psychological circumstances (see Table 1). Shedding light into what these experiences entail may help clinicians assess for moral injury in their own patients.

Moral Injury vs. Posttraumatic Stress Disorder (PTSD)

After the Vietnam War, service members coming home endured troubling psychological effects that led to the diagnosis, research, and treatment of PTSD, which made significant progress in the psychiatric care of the U.S. military population. The fear-related symptoms of PTSD alone, however, may fail to fully capture the suffering in the aftermath. It is often what these veterans did, or did not do, in war that continues to haunt them. This is best described as moral injury.

The importance of this internal commotion is apparent in the writing of former marine Gibbons-Neff (7), who stated that “moral injury isn’t so much about how the country understands its veterans; rather it is about how veterans understand themselves.” Not all those suffering from PTSD have moral injury, and, conversely, not all of those with moral injury have PTSD. In addition, an individual suffering from moral injury does not necessarily need to have experienced a trauma of the type required for a PTSD diagnosis (8). It is important to emphasize, however, that moral injury and PTSD can coexist.

Moral Injury and Psychiatric Ramifications

Moral injury explores the contributions of the guilt and shame to postdeployment psychopathology (4). When talking about moral injury, it is important to distinguish guilt versus shame. Guilt is an evaluation of the morality of an action, which creates an opportunity for forgiveness. Shame, on the other hand, is a global evaluation of the self, which leads to self-condemnation, avoidance, and withdrawal (9). Avoidance, in turn, further limits reparative experiences and social connection, resulting in individuals suffering in isolation (2). Signs of moral injury can include interpersonal difficulties, distrust, spiritual/existential crises, psychological problems, anger, substance use, self-destructive behaviors, and self-deprecation (4, 10).

Improving our understanding of moral injury may allow us to devise treatments that target these wounds and address what might be another risk factor for suicide among veterans. The importance of better treatment for combat veterans cannot be overemphasized, given that since 2012, death by suicide is greater than by combat among active-duty soldiers (11). PTSD often focuses on being the victim of a traumatic experience, but it neglects the psychological effects of perceiving that one is the perpetrator even in situations of prescribed acts of killing, such as in war. Studies have shown that being a target of another’s attempt to kill or injure is associated with PTSD, while having been the agent of killing someone or failing to prevent death and injury is correlated more strongly with suicide attempts, suicidal ideation, anger, alcohol use disorders, relationship problems, weakened religious faith, and overall greater psychiatric distress (10, 12–14). A recent study examining different combat experiences found that the act of killing or believing one killed the enemy and firing a weapon at the enemy were associated with increased suicidal ideation. Overall, this study revealed that while the act of killing predicted suicidal ideation with statistical significance, it was not more predictive of PTSD (15). This suggests that moral injury may account for a greater proportion of psychopathology than previously recognized.

Screening Tools

In order to better address soldiers and veterans suffering from moral injury, assessment instruments could be invaluable tools. Currently, two scales for moral injury have been developed, although neither is yet widely used. One is the 20-item Moral Injury Questionnaire-Military version, which attempts to capture morally injurious events experienced by military populations (16). Higher scores on this questionnaire are associated with poorer work and social adjustments and more severe PTSD and depressive symptoms. The other assessment is the 9-item Moral Injury Events Scale relating to perceived transgressions and perceived betrayals (17, 18). This scale has been shown to have good internal consistency and correlate with other measures of psychiatric distress and can be used to evaluate for prevalence and perceived intensity of morally injurious experiences. Further research in the validity of these scales with different military branches, both genders, and different operational roles are needed, but these assessment instruments may still serve as initial screening tools to capture veterans’ experiences with moral injury and their level of distress from it.

Another idea suggested by Nazarov et al. (9) is the creation of a validated assessment tool for identifying individuals at risk and creating early intervention programs. Because shame is central to moral injury and appears to mediate onset of psychopathology, including PTSD, and depression, and possibly increase risk of suicide, individuals more prone to shame may fit into the “at-risk” population (9). The Test of Self-Conscious Affect-3 scale, created by Tangney et al. (19), is one of the most widely used shame scales and separates responses into four categories, including guilt-proneness, shame-proneness, detachment, and externalization of blame. Theoretically, individuals scoring high in the shame-proneness category potentially may be more vulnerable to moral injury and benefit from early intervention programs.

Possible Treatments

Because research in this field is still in its infancy, treatment of moral injury is still developing. Cognitive processing therapy and prolonged exposure have significant evidence for treatment of military PTSD, but patients also suffering from moral injury may need a special focus targeting the moral dissonance and shame that accompanies moral injury. The first published trial of treatment specifically targeting inner conflicts from morally challenging experiences was referred to as adaptive disclosure. Adaptive disclosure was initially developed for active-duty service members and is composed of six 90-minute sessions, which entail a combination of exposure therapy and cognitive processing therapy but sequences them specifically to target experiences that produce moral injury. Adaptive disclosure includes processing memories and exploring meaning of the experience, and individuals also carry out imaginable conversations with a caring moral authority or a key relevant “other,” such as the deceased (20).

Another treatment approach is acceptance and commitment therapy for moral injury. Acceptance and commitment therapy focuses not on trying to change the shame and guilt that comes with the moral injury but rather on accepting it while not letting it dictate the individual’s life.

Drescher et al. (4) explored commentaries regarding moral injury based on a diverse group of health and religious professionals experienced in working with military populations; some of the suggested approaches included interventions at the spiritual, social, and individual levels, which suggests that a multidisciplinary approach may be the optimal solution for such a complex issue. Group therapy may also be helpful, as social support can serve as powerful healing tools in moral injury (5). An important concept when considering treatment modalities for moral injury is that in moral injury, an individual’s judgments and beliefs about a moral transgression may be accurate and appropriate and need to be validated, while promoting acceptance of an imperfect self, as well as self-forgiveness and self-empathy (18).

Conclusions

The construct of moral injury is paramount to understanding the internal ethical and spiritual conflicts veterans are left with, which account for a significant unaddressed part of their psychopathology. Further research in this field is indispensable to cultivate a better life for our service members and veterans. Raising awareness and appropriate development and use of screening tools are important subsequent steps in the field of moral injury.

Key Points/Clinical Pearls