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

Abstract

The findings from the present study supported an existing model of moral injury, while extending it in several important ways. Preliminary clinical recommendations and directions for future research are discussed based on the study findings. These include directly exploring the context surrounding the morally injurious event, examining the veterans' moral appraisals, and helping them assume appropriate responsibility for their actions to reduce excessive self-blame. (PsycINFO Database Record

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

“…In the moral injury framework, the guilt and shame engendered by perpetrating morally injurious events are conceptualized as being, at some level, an appropriate and not irrational response ( 19 , 20 ). Both guilt and shame may be salutary in that they may signal an intact conscience and promote prosocial reparative behavior and interpersonal reconnection ( 21 , 22 ). A handful of studies have tested the associations between combat, guilt, and moral injury outcomes ( 23 – 26 ).…”

Moral Injury

“…Regions of interest were brain areas researchers have previously reported as being activated by fear stimuli, including the bilateral amygdala and the right rostral anterior cingulate cortex, and regions reported as being activated by traumatic script imagery, including the right dorsal anterior cingulate cortex, the left posterior cingulate cortex, and the left precuneus. Results show that veterans who had experienced danger-and/or fear-based traumas had higher metabolism in the amygdalae, whereas veterans who had experienced non-danger-based traumas had higher metabolism in the precuneus, which is interestingly related to self-referential processing (Barnes et al, 2019;Held et al, 2019;Ramage et al, 2016).…”

“…Narrative analyses of veterans' lived experiences with transgressions of their moral beliefs similarly show that the feelings experienced after a moral transgression are qualitatively different from those described by individuals diagnosed with PTSD (Drescher et al, 2011;Held et al, 2019;Vargas et al, 2013). Thus, the PTSD construct only partially describes the development and subsequent sequelae of moral injury.…”

“…Furthermore, individuals who have endured perpetration-based and morally injurious traumatic experiences encounter sequelae that are distinct from the sequelae encountered by those with life-threat traumatic experiences. While life-threat traumas typically arouse fear and elicit hyperarousal difficulties and symptoms of PTSD, perpetration-based and morally injurious traumas tend to be characterized by feelings of shame, guilt, anger, and/or self-blame and elicit reexperiencing, avoidance, self-injurious behavior, and meaning making difficulties, including spiritual struggles and a shattering of one's assumptive and/or spiritual world (Antal & Winings, 2015;Currier et al, 2019;Drescher et al, 2011;Farnsworth et al, 2014;Frankfurt & Frazier, 2016;Griffin et al, 2019;Harris et al, 2015;Held et al, 2019;Hodgson & Carey, 2017;Kopacz et al, 2016;Kopacz et al, 2015;Litz et al, 2009;Maguen & Litz, 2012;Neria & Pickover, 2019;Sreenivasan et al, 2014;Starnino et al, 2019;Steinmetz et al, 2019;Vargas et al, 2013;Yeterian et al, 2019;Zerach & Levi-Belz, 2019).…”

“…In war and combat, being violent and killing is sanctioned and normal, and military training prepares service members to participate in and bear witness to the violence and killing in war (Antal & Winings, 2015;Doehring, 2019;Drescher et al, 2011;Farnsworth et al, 2014;Harris et al, 2015;Litz et al, 2009). In order to survive in such a threatening and intense context, service members must be nonreactive, make quick decisions, put their lives at risk, and perform acts that would otherwise be illegal or unethical in most other contexts (Davies et al, 2019;Drescher et al, 2011;Farnsworth et al, 2014;Held et al, 2019). In military culture, when a leader tells you to do something, it is morally sanctioned.…”