"I knew it was wrong the moment I got the order": A narrative thematic analysis of moral injury in combat veterans

A Scoping Review of Military Culture, Military Identity, and Mental Health Outcomes in Military Personnel

INTRODUCTION

The military is a unique cultural institution that significantly influences its members, contributing to the development and transformation of their identities. Despite growing interest in identity research in the military, challenges persist in the conceptualization of military identity, including understanding how it forms, assessing the influence of military culture on identity development, and evaluating the implications for mental health. The primary objective of this scoping review was to map the complexities of military culture's impact on military identity and its effects on mental health.

MATERIALS AND METHODS

A scoping review of the literature was conducted using the Joanna Briggs Institute Scoping Review Methodology. Studies were included if they described military culture, military identity, and mental health, resulting in 65 eligible studies. The extracted data were thematically analyzed to identify how military culture impacts military identity and mental health and well-being.

RESULTS

Multiple identities were evident within the military population, with 2 overarching identities, loyalty and military, overall conferring positive mental health outcomes. Where these identities were hidden or disrupted, poorer mental health outcomes were observed.

CONCLUSIONS

The scoping review conducted in this study challenges the notion of military identity as a singular concept promoting positive mental health outcomes. It highlights its multifaceted nature, revealing that individuals may face identity concealment and disruptions during periods of transition or adjustment, resulting in adverse mental health outcomes. To capture the complexity of military identity, the authors developed the Military Identity Model (MIM). Military leaders, policymakers, and health care professionals are encouraged to recognize the complex nature of military identity and its impact on mental health and well-being. We recommend using the Military Identity Model to explore military identity and adjustment-related difficulties.

"Caught in the crossfire" - women veterans' testimonies regarding excessively violent acts committed in combat zones

As women in the Israeli Defense Forces (IDF) are increasingly placed in supportive and combat roles in active war zones, they routinely encounter and participate in violent acts. This study focusses on the centrality of gendered inequality and oppression as a factor that shapes not only women's experience in the military but also their responses in cases of excessive violence. The goal of this study was to explore the ways women veterans of combat or combat-support units conceptualize their stance regarding violent acts which they either committed or witnessed in war zones. Using a qualitative approach, we analyzed the retrospective testimonies of 58 Israeli women veterans from the archives of an NGO that documents veteran combatants exposure to excessive violence. Most women explained their violent acts as inherent to the military system and culture, which in our analysis was categorized as examples of either internalized gender oppression or as identification with the aggressor. A smaller number of women described their attempts to protest, as they took a moral stance rooted in a feminine perspective. The three explanations revealed through the analysis of the testimonies reflect the inner tension experienced by many women in the military, as they navigate between two extreme positions, either as victims of male dominance, or as aggressors that are part of a powerful military system. In this study, gendered inequality provides a framework for analyzing the data. Thus, this study contributes to the theoretical knowledge and methodological approaches concerning violent situations in combat areas, focusing on the various ways in which women veterans subjectively and retroactively conceptualize their participation in and responses to violent acts.

Examining the health and wellness of solo self-employed workers through narratives of precarity: a qualitative study

BACKGROUND

In recent decades, there has been a significant transformation in the world of work that is characterized by a shift from traditional manufacturing and managerial capitalism, which offered stable full-time employment, to new forms of entrepreneurial capitalism. This new paradigm involves various forms of insecure, contingent, and non-standard work arrangements. Within this context, there has been a noticeable rise in Self-Employed individuals, exhibiting a wide range of -working arrangements. Despite numerous investigations into the factors driving individuals towards Self-Employment and the associated uncertainties and insecurities impacting their lives and job prospects, studies have specifically delved into the connection between the precarious identity of Self-Employed workers and their overall health and well-being. This exploratory study drew on a 'precarity' lens to make contributions to knowledge about Self-Employed workers, aiming to explore how their vulnerable social position might have detrimental effects on their health and well-being.

METHODS

Drawing on in-depth interviews with 24 solo Self-Employed people in Ontario (January - July 2021), narrative thematic analysis was conducted based on participants' narratives of their work experiences. The dataset was analyzed with the support of NVIVO qualitative data analysis software to elicit narratives and themes.

FINDINGS

The findings showed that people opt into Self-Employment because they prefer flexibility and autonomy in their working life. However, moving forward, in the guise of flexibility, they encounter a life of precarity, in terms of job unsustainability, uncertainties, insecurities, unstable working hours and income, and exclusion from social benefits. As a result, the health and well-being of Self-Employed workers are adversely affected by anger, anomie, and anxiety, bringing forward potential risks for a growing population.

CONCLUSION AND IMPLICATIONS

Neoliberalism fabricates a 'precariat' Self-Employed class. This is a social position that is vague, volatile, and contingent, that foreshadows potential threats of the health and wellbeing of a growing population in the changing workforce. The findings in this research facilitate some policy implications and practices at the federal or provincial government level to better support the health and wellbeing of SE'd workers.

Self-employment, illness, and the social security system: a qualitative study of the experiences of solo self-employed workers in Ontario, Canada

BACKGROUND

Today's labor market has changed over time, shifting from mostly full-time, secured, and standard employment relationships to mostly entrepreneurial and precarious working arrangements. Thus, self-employment (SE) has been growing rapidly in recent decades due to globalization, automation, technological advances, and the recent rise of the 'gig' economy, among other factors. Accordingly, more than 60% of workers worldwide are non-standard and precarious. This precarity profoundly impacts workers' health and well-being, undermining the comprehensiveness of social security systems. This study aims to examine the experiences of self-employed (SE'd) workers on how they are protected with available social security systems following illness, injury, and income reduction or loss.

METHODS

Drawing on in-depth interviews with 24 solo SE'd people in Ontario (January - July 2021), thematic analysis was conducted based on participants' narratives of experiences with available security systems following illness or injury. The dataset was analyzed using NVIVO qualitative software to elicit narratives and themes.

FINDINGS

Three major themes emerged through the narrative analysis: (i) policy-practice (mis)matching, (ii) compromise for a decent life, and (iii) equity in work and benefits.

CONCLUSIONS

Meagre government-provided formal supports may adversely impact the health and wellbeing of self-employed workers. This study points to ways that statutory social protection programs should be decoupled from benefits provided by employers. Instead, government can introduce a comprehensive program that may compensate or protect low-income individuals irrespective of employment status.

Negative cognition in the context of suicidality after exposure to military-related potentially morally injurious events

LAY SUMMARY

Moral injury (MI) refers to the psycho-spiritual consequences of events that deeply transgress a person’s core moral beliefs and values. Such events are reportedly common in the military context, and strong associations have been demonstrated between exposure to potentially morally injurious events (PMIEs) and suicidality. This study explored differences in negative cognitions between treatment-seeking Canadian Armed Forces members and Veterans with and without current suicidal thoughts and behaviours (STBs), all of whom reported current distress in response to a PMIE. Those exhibiting STBs reported stronger negative beliefs about the self. Scores for event-related guilt cognitions and self-blame were similar across individuals with and without STBs. Individuals reporting STBs also displayed higher depression and symptoms of posttraumatic stress disorder. The results suggest that severity of mental health symptoms and negative self-evaluations may be most pertinent in their association with suicidality in the MI context. Results remain preliminary, however, and additional research is needed to properly examine how event and self-related evaluations affect suicidality after PMIEs.

The Moral Injury Experience Wheel: An Instrument for Identifying Moral Emotions and Conceptualizing the Mechanisms of Moral Injury

This paper introduces an infographic tool called The Moral Injury Experience Wheel, designed to help users accurately label moral emotions and conceptualize the mechanisms of moral injury (MI). Feeling wheels have been used by therapists and clinical chaplains to increase emotional literacy since the 1980s. The literature on the skill of emotion differentiation shows a causal relationship between identifying emotions with specificity and emotional and behavioral regulation. Emerging research in moral psychology indicates that differentiating moral emotions with precision is related to similar regulatory effects. Based on this evidence, it is proposed that increasing moral emotional awareness through use of an instrument that visually depicts moral emotions and their causal links to MI will enhance appraisal and flexible thinking skills recognized to reduce the persistent dissonance and maladaptive coping related to MI. Design of the wheel is empirically grounded in MI definitional and scale studies. Iterative evaluative feedback from Veterans with features of MI offers initial qualitative evidence of validity. Two case studies will show utility of the wheel in clinical settings and present preliminary evidence of efficacy.

'Against everything that got you into the job': experiences of potentially morally injurious events among Canadian public safety personnel

Background: Moral injury (MI) has become a research and organizational priority as frontline personnel have, both during and in the years preceding the COVID-19 pandemic, raised concerns about repeated expectations to make choices that transgress their deeply held morals, values, and beliefs. As awareness of MI grows, so, too, does attention on its presence and impacts in related occupations such as those in public safety, given that codes of conduct, morally and ethically complex decisions, and high-stakes situations are inherent features of such occupations.Objective: This paper shares the results of a study of the presence of potentially morally injurious events (PMIEs) in the lived experiences of 38 public safety personnel (PSP) in Ontario, Canada.Method: Through qualitative interviews, this study explored the types of events PSP identify as PMIEs, how PSP make sense of these events, and the psychological, professional, and interpersonal impacts of these events. Thematic analysis supported the interpretation of PSP descriptions of events and experiences.Results: PMIEs do arise in the context of PSP work, namely during the performance of role-specific responsibilities, within the organizational climate, and because of inadequacies in the broader healthcare system. PMIEs are as such because they violate core beliefs commonly held by PSP and compromise their ability to act in accordance with the principles that motivate them in their work. PSP associate PMIEs, in combination with traumatic experiences and routine stress, with adverse psychological, professional and personal outcomes.Conclusion: The findings provide additional empirical evidence to the growing literature on MI in PSP, offering insight into the contextual dimensions that contribute to the sources and effects of PMIEs in diverse frontline populations as well as support for the continued application and exploration of MI in the PSP context.

Secondary Traumatic Stress and Moral Injury in Maternity Care Providers: A Narrative and Exploratory Review

Introduction

A significant percentage of maternity providers have experienced secondary traumatic stress following a traumatic birth. Previous studies identified it as an issue, but this literature review is 5–9 years old. In addition, the construct of moral injury has significantly increased our understanding of secondary trauma for military veterans. In the wake of COVID-19, this construct also applies to healthcare providers.

Objectives

The present article updates these reviews and compares findings for three groups: labor and delivery nurses, midwives, and obstetricians. The second portion of this review re-examines previously published qualitative research to determine whether moral injury might more accurately describe the experiences of maternity personnel.

Methods

A comprehensive review of PubMed, Scopus, Web of Science, PsychINFO, and CINAHL was conducted in June 2021 using search terms such as compassion fatigue, secondary trauma, moral injury, labor and delivery, nurses, midwives, and obstetricians. Forty articles were identified, but only 16 focused on secondary trauma or moral injury.

Results

Secondary trauma is a significant concern affecting at least 25% of maternity staff. However, some countries have very low rates, which correspond to low rates in childbirth-related trauma in mothers. Secondary trauma can lead to several symptoms, including re-experiencing, avoidance, negative changes in mood and cognitions, and hyperarousal, which can cause significant impairment. As a result, many providers decide to leave the field in the wake of a traumatic birth. The incidence of moral injury is unknown, but a re-examination of previously published qualitative data suggests that this construct, generally used to describe combat veterans, does describe some of what providers have reported. Acts of omission, i.e., failure to stop the harmful acts of others had long-term negative effects on labor and delivery nurses, consistent with data from military samples. Two possible mediators were proposed: hierarchical and gendered relationships in hospitals and agency of care.

Conclusion

The effects of traumatic birth on providers can be severe, including possible psychological sequelae, impaired job performance, and leaving the field. Moral injury expands upon the construct of secondary traumatic stress. This construct better describes the experiences of maternity staff in non-primary roles who witness traumatic births and are often haunted by events that they could not prevent, but often question whether they should have.

Patterns of distress associated with exposure to potentially morally injurious events among Canadian Armed Forces service members and Veterans: A multi-method analysis

OBJECTIVE

This study describes patterns of distress associated with exposure to potentially morally injurious experiences (PMIEs) in a Canadian military sample.

METHOD

Thematic analysis was performed on interviews from PMIE-exposed military members and Veterans. Participants also completed structured diagnostic interviews, and measures of trauma exposure and psychopathology. Multiple regression examined associations among these variables. Information on pharmacological treatment and past diagnoses are reported.

RESULTS

Eight qualitative themes were identified: changes in moral attitudes, increased sensitivity and reactivity to moral situations, loss of trust, disruptions in identity, disruptions in spirituality, disruptions in interpersonal relatedness, rumination, and internalizing and externalizing emotions and behaviors. Self-report data revealed that degree of PMIE exposure was meaningfully associated with posttraumatic stress disorder.

CONCLUSION

Qualitative but not quantitative findings supported existing models of moral injury (MI). Additional research is needed to examine the impact of PMIE type on mental health, and to test basic assumptions of MI theory.

Do morally injurious experiences and index events negatively impact intensive PTSD treatment outcomes among combat veterans?

Background: It has been suggested that current frontline posttraumatic stress disorder (PTSD) treatments are not effective for the treatment of moral injury and that individuals who have experienced morally injurious events may respond differently to treatment than those who have not. However, these claims have yet to be empirically tested. Objective: This study evaluated the rates of morally injurious event exposure and morally injurious index trauma and their impact on PTSD (PCL-5) and depression symptom (PHQ-9) reductions during intensive PTSD treatment. Method: Data from 161 USA military combat service members and veterans (91.3% male; mean age = 39.94 years) who participated in a 3-week Cognitive Processing Therapy (CPT)-based intensive PTSD treatment programme (ITP) was utilized. Morally injurious event exposure was established via the Moral Injury Event Scale (MIES). Index traumas were also coded by the treating clinician. Linear mixed effects regression analyses were conducted to examine if differences in average effects or trends over the course of treatment existed between veterans with morally injurious event exposure or index trauma and those without. Results: Rates of morally injurious event exposure in this treatment sample were high (59.0%-75.2%). Morally injurious event exposure and the type of index trauma did not predict changes in symptom outcomes from the ITP and veterans reported large reductions in PTSD (d = 1.35-1.96) and depression symptoms (d = 0.95-1.24) from pre- to post-treatment. Non-inferiority analyses also demonstrated equivalence across those with and without morally injurious event exposure and index events. There were no significant gender differences. Conclusions: The present study suggests that PTSD and depression in military veterans with morally injurious event exposure histories may be successfully treated via a 3-week CPT-based ITP.

The moderating role of emotion dysregulation in the relation between potentially morally injurious experiences and alcohol misuse among military Veterans

Alcohol misuse is a serious and pervasive problem among US military Veterans. The commission or omission of acts that transgress important moral standards, known as potentially morally injurious events (PMIEs), has been theoretically and empirically linked to alcohol misuse in this population. Emotion dysregulation has been implicated in the pathogenesis of alcohol misuse and may be relevant in the context of PMIEs. The goal of this study was to examine the roles of negative and positive emotion dysregulation in the relation between PMIEs and alcohol misuse. Participants were a community sample of US military Veterans who were predominantly white (69.5%) and male (71.6%), with a mean age of 38.00. The interaction between PMIEs and both negative and positive emotion dysregulation (separately) significantly predicted alcohol misuse. Simple slopes tests revealed that the relation between PMIEs and alcohol misuse was only significant at high levels of negative and positive emotion dysregulation. Findings underscore the potential utility of targeting both negative and positive emotion dysregulation in alcohol misuse interventions for military Veterans experiencing PMIEs.

Commentary on the Special Issue on Moral Injury: Leveraging Existing Constructs to Test the Heuristic Model of Moral Injury

The literature on moral injury (MI) is currently undermined by the lack of clear boundaries regarding the construct and a dearth of research on the processes by which potentially morally injurious events lead to MI. The heuristic continuum model of moral stressors proposes ways of distinguishing between moral frustrations, moral distress, and MI. In this commentary, we highlight five testable principles that can be derived from the heuristic model and evaluated using well-established constructs. Specifically, we describe meaningful distinctions between guilt and shame and address how these moral emotions can be used to distinguish between moral distress and MI. We also describe the potential role of event-related rumination, shame proneness, and cognitive flexibility in the development of MI following exposure to potentially morally injurious events. We believe that these principles offer critical next steps for the advancement of the MI field and illustrate how MI research can be generalized beyond the military context.

Defining Moral Injury Among Military Populations: A Systematic Review

Military service often requires engaging in activities, witnessing acts, or immediate decision-making that may violate the moral codes and personal values to which most individuals ascribe. If unacknowledged, these factors can lead to injuries that can affect the physical, psychological, social, and spiritual health of military men and women. The term moral injury has been assigned to these soul-ceasing experiences. Although researchers have attempted to define moral injury and what leads to such experiences, inconsistencies across definitions exist. In addition, nearly all existing definitions have lacked empirical support. The purpose of the present systematic review was to explore how moral injury has been defined in research with military populations, using Cooper's approach to research synthesis as well as PRISMA guidelines. An in-depth review of 124 articles yielded 12 key definitions of moral injury across the literature. Two of these 12 definitions were grounded in empirical evidence, suggesting that much more research is needed to strengthen the face validity and reliability of the construct. Quality rankings were developed to categorize each of the included articles. The findings punctuate the need for empirical evidence to further explore moral injury, particularly among samples inclusive of service members and the biopsychosocial-spiritual experiences associated with such injuries.

Meaning in life moderates the association between morally injurious experiences and suicide ideation among U.S. combat veterans: Results from the National Health and Resilience in Veterans Study

OBJECTIVE

Effectively responding to suicide risk among veterans involves further developing understanding of reactions to combat experiences, including life-threatening events, traumatic losses, and morally injurious experiences. An important determinant of whether stressors lead to poor mental health outcomes is the perception of meaning. The current study aimed to determine whether global meaning (i.e., general beliefs, goals, and sense of purpose in life) moderates the relationship between morally injurious experiences and suicide ideation among combat veterans.

METHOD

This analysis examined 564 participants in the National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of U.S. military veterans, who reported a history of deployment to a combat zone. Multivariable logistic regressions examined interactions between morally injurious experiences and global meaning as predictors of the likelihood of current suicide ideation.

RESULTS

There were significant interactions between global meaning and 2 morally injurious experience subtypes-transgressions by others and betrayal experiences. Higher global meaning was associated with significantly lower likelihood of experiencing suicide ideation at higher levels of transgression by others and betrayal experiences.

CONCLUSIONS

Veterans who report higher levels of morally injurious experiences involving transgressions by others and betrayal experiences in the presence of higher levels of global meaning are significantly less likely to experience suicide ideation. Continued research is needed to determine whether interventions aimed at cultivating global meaning may help mitigate suicide risk in combat veterans with high exposure to certain potentially morally injurious experiences. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Mechanisms of Moral Injury Following Military Sexual Trauma and Combat in Post-9/11 U.S. War Veterans

Objective: Moral injury may result from perpetration-based and betrayal-based acts that violate deeply held norms; however, researchers and clinicians have little guidance about the moral injury syndrome's specific developmental pathways following morally injurious events. The present study's objective was to examine the direct and indirect pathways proposed in a frequently cited model of moral injury (1) in relation to two types of military-related traumas [experiencing military sexual trauma (MST) and combat exposure]. Methods: Secondary analyses were conducted within a sample of post-9/11 veterans at a Southwestern Veterans Health Care System (N = 310) across two time-points. Structural equation modeling tested the direct and indirect pathways from MST and combat to a PTSD-depression factor via betrayal, perpetration, guilt, and shame. Results: Betrayal accounted for the association between MST and PTSD-depression (β = 0.10, p < 0.01, 95% CI = 0.01 - 0.11) and perpetration accounted for the association between combat and PTSD-depression (β = 0.07, p < 0.05, 95% CI = 0.02 - 0.14). The indirect path from combat to shame to PTSD-depression was significant (β = 0.16, p < 0.01, 95% CI = 0.07 - 0.28) but the path through guilt was not. The specific indirect paths through perpetration or betrayal to shame or guilt were non-significant. Conclusions: Betrayal and perpetration are associated with PTSD-depression following MST and combat. Results suggest multiple pathways of moral injury development following different military traumas and morally injurious events. Implications for moral injury conceptualization and treatment are discussed.