A moral injury results when those exposed to combat are placed into a situation within which there is no choice but to violate his/her moral code. It commonly occurs in combat environments, and veterans are not adequately prepared for, nor advised about, the inevitable consequences on their lives. Society must be part of the cure for this complex, greatly misunderstood, often lethal and always disabling invisible wound which causes symptoms ranging across depression, anxiety, nightmares, drug and alcohol addiction, erratic behaviors and a general sense of worthlessness and helplessness. The problem is too widespread, complex and enduring to be treated effectively by Veterans Administration hospital staffs.
Below is an article by Shira Maguen, PhD and Brett Litz, PhD as found on the National Center for PTSD’s website.
Moral Injury in the Context of War
By Shira Maguen, PhD and Brett Litz, PhD
What is Moral Injury?
Like psychological trauma, moral injury is a construct that describes extreme and unprecedented life experience including the harmful aftermath of exposure to such events. Events are considered morally injurious if they “transgress deeply held moral beliefs and expectations” (1). Thus, the key precondition for moral injury is an act of transgression, which shatters moral and ethical expectations that are rooted in religious or spiritual beliefs, or culture-based, organizational, and group-based rules about fairness, the value of life, and so forth.
Moral injury in war
In the context of war, moral injuries may stem from direct participation in acts of combat, such as killing or harming others, or indirect acts, such as witnessing death or dying, failing to prevent immoral acts of others, or giving or receiving orders that are perceived as gross moral violations (2). The act may have been carried out by an individual or a group, through a decision made individually or as a response to orders given by leaders.
- Unintentional errors: Military personnel are well trained in the rules of engagement and do a remarkable job making life or death decisions in war; however, sometimes unintentional error leads to the loss of life of non-combatants, setting the stage for moral injury.
- Transgressive acts of others: Service members can be morally injured by the transgression of peers and leaders who betray expectations in egregious ways.
What is the aftermath of moral injury?
In terms of the aftermath of moral injuries, transgressive acts may result in highly aversive and haunting states of inner conflict and turmoil. Emotional responses may include:
- Shame, which stems from global self-attributions (for example “I am an evil terrible person; I am unforgivable”)
- Anxiety about possible consequences
- Anger about betrayal-based moral injuries
Behavioral manifestations of moral injury may include:
- Anomie (for example alienation, purposelessness, and/or social instability caused by a breakdown in standards and values)
- Withdrawal and self-condemnation
- Self-harming (for example suicidal ideation or attempts)
- Self-handicapping behaviors (for example alcohol or drug use, self-sabotaging relationships, etc.)
Additionally, moral injury has been posited to result in the re-experiencing, emotional numbing, and avoidance symptoms of PTSD (1). In addition to grave suffering, these manifestations of moral injury may lead to under- or unemployment, and failed or harmed relationships with loved ones and friends.
Can killing cause moral injury?
Several studies demonstrate an association between killing in war and mental and behavioral health problems, which may be proxies for moral injury (3-8).
- Across eras (for example Vietnam, Operations Desert Storm and Desert Shield, Operation Iraqi Freedom [OIF], Operation Enduring Freedom [OEF]) those who kill in war are at greater risk for a number of mental health consequences and functional difficulties, including PTSD, after accounting for a number of demographic variables and other indicators of combat exposure (3-5).
- In returning OIF Veterans, even after controlling for combat exposure, taking another life was a significant predictor of PTSD symptoms, alcohol abuse, anger, and relationship problems (3).
- Vietnam Veterans who reported killing were twice as likely to report suicidal ideation as those who did not, even after accounting for general combat exposure, PTSD and depression diagnoses (9). In OIF Veterans, the relationship between killing and suicidal ideation was mediated by PTSD and depression symptoms (10).
- Killing in war may be an important indicator of risk for developing frequent and severe PTSD symptoms. Three-quarters of individuals who killed were in the two most severe PTSD symptom classes, and those who killed had twice the odds of being in the most symptomatic PTSD class, compared to those who did not kill. Those who endorsed killing a non-combatant or killing in the context of anger or revenge were more likely to belong to the most symptomatic PTSD class, compared to those who did not kill (11).
Although killing may be a precursor to moral injury, it is important to note that not all killing in war results in adverse outcomes for military personnel. As noted earlier, certain elements need to be present for moral injury to occur, including a perceived transgression that goes against individual or shared moral expectations.
For example, a military member who kills an enemy combatant in self-defense may perceive that the death was justified. If however, a civilian was perceived to be armed and consequently killed, with military personnel later discovering that the individual was in fact unarmed, this may set the stage for the development of moral injury.
Are moral injury and PTSD the same?
More research is needed to answer this question. At present, although the constructs of PTSD and moral injury overlap, each has unique components that make them separable consequences of war and other traumatic contexts.
- PTSD is a mental disorder that requires a diagnosis. Moral injury is a dimensional problem – there is no threshold for the presence of moral injury, rather, at a given point in time, a Veteran may have none, or mild to extreme manifestations.
- Transgression is not necessary for PTSD to develop nor does the PTSD diagnosis sufficiently capture moral injury (shame, self-handicapping, guilt, etc.).
Consequently, it is important to assess mental health symptoms and moral injury as separate manifestations of war trauma to form a comprehensive clinical picture, and provide the most relevant treatment. One example of a moral injury specific measure is the Moral Injury Events Scale (12).
- Litz, B.T., Stein, N., Delaney, E., Lebowitz, L., Nash, W.P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war Veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29,695-706.
- Drescher, K. D., Foy, D. W., Kelly, C., Leshner, A., Schutz, A., & Litz, B.T. (2011). . An exploration of the viability and usefulness of the construct of moral injury in war Veterans. Traumatology, 17, 8-13. doi: 10.1177/1534765610395615
- Maguen, S., Metzler, T.J., Litz, B.T., Seal, K.H., Knight, S.J., & Marmar, C.R. (2009). The impact of killing in war on mental health symptoms and related functioning. Journal of Traumatic Stress, 22, 435-443. doi: 10.1002/jts.20451
- Maguen, S., Lucenko, B.A., Reger, M.A., Gahm, G.A., Litz, B.T., Seal, K.H., Knight, S.J., & Marmar, C.R. (2010). The impact of reported direct and indirect killing on mental health symptoms in Iraq War Veterans. Journal of Traumatic Stress, 23, 86-90.
- Maguen, S., Vogt, D.S., King, L.A., King, D.W., Litz, B.T., Knight, S.J., & Marmar, C.R. (2011).The impact of killing on mental health symptoms in Gulf War Veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 3 21-26. doi: 10.1037/a0019897.
- Fontana, A., Rosenheck, R. & Brett, E. (1992). War zone traumas and posttraumatic stress disorder symptomatology. Journal of Nervous and Mental Disease, 180, 748-755.
- MacNair, R.M. (2002). Perpetration-inducted traumatic stress in combat Veterans.Peace and Conflict: Journal of Peace Psychology, 8, 63-72. doi: 10.1207/S15327949PAC0801_6
- Fontana, A. & Rosenheck, R. (1999). A model of war zone stressors and posttraumatic stress disorder. Journal of Traumatic Stress, 12, 111-26. doi: 10.1023/A:1024750417154
- Maguen, S., Metzler, T.J., Bosch, J., Marmar, C.R., Knight, S.J., & Neylan, T.C. (2012) Killing in combat may be an independently associated with suicidal ideation. Depression & Anxiety, 29, 918-23. doi: 10.1002/da.21954
- Maguen, S., Luxton, D.D., Skopp, N.A., Gahm, G.A., Reger, M.A., Metzler, T.J., & Marmar, C.R. (2011). Killing in combat, mental health symptoms, and suicidal ideation in Iraq War Veterans. Journal of Anxiety Disorders, 25, 563-567. doi: 10.1016/j.janxdis.2011.01.003
- Maguen, S., Madden, E., Bosch, J., Galatzer-Levy, I., Knight, S. J., Litz, B. T., Marmar, C. R., & McCaslin, S. E., (2013). Killing and latent classes of PTSD symptoms in Iraq and Afghanistan Veterans. Journal of Affective Disorders, 145, 344-348. doi: 10.1016/j.jad.2012.08.021
- Nash, W. P., Mariano Carper, T. L., Mills, M. A., Au, T., Goldsmith, A., & Litz, B. T., (2013). Psychometric evaluation of the Moral Injury Events Scale. Military Medicine, 178, 646-652. doi: 10.7205/MILMED-D-13-00017
- Steenkamp, M. M., Nash, W. P., Lebowitz, L., & Litz, B. T. (2013). How best to treat deployment-related guilt and shame: Commentary on Smith, Duax, and Rauch (2013). Cognitive and Behavioral Practice, 20, 471-475. doi: 10.1016/j.cbpra.2013.05.002
- Maguen, S., & Burkman, K. (2013). Combat-related killing: Expanding evidence-based treatments for PTSD. Cognitive and Behavioral Practice, 20, 476-479. doi: 10.1016/j.cbpra.2013.05.003
- Resick, P. A., Monson, C. M., & Chard, K. M. (2014). Cognitive processing therapy: Veteran/military version: Therapist’s manual. Washington, DC: Department of Veterans Affairs.
- Smith, E. R., Daux, J. M., & Rauch, S. M. (2013). Perceived perpetration during traumatic events: Clinical suggestions from experts in prolonged exposure therapy. Cognitive and Behavioral Practice, 20, 461-470. doi: 10.1016/j.cbpra.2012.12.002
- Maguen, S., & Burkman, K. (2014, May 22). Killing in war and moral injury: Research and clinical implications. Invited lecture presented at 17th Annual VA Psychology Leadership Conference, San Antonio, TX.
- Burkman, K., Madden, E., Bosch, J., Dinh, J., Neylan, T., & Maguen, S. (2013, November 8). Preliminary findings from a pilot study of a novel treatment among Veterans with PTSD who have killed in war. Paper presented at the International Society for Traumatic Stress Studies 29th Annual Meeting, Philadelphia, PA.
- Steenkamp, M., Litz, B. T., Gray, M., Lebowitz, L., Nash, W., Conoscenti, L., Amidon, A., & Lang, A., (2011). A brief exposure-based intervention for service members with PTSD. Cognitive and Behavioral Practice, 18, 98-107. doi: 10.1016/j.cbpra.2009.08.006
- Gray, M.J., Schorr, Y., Nash, W., Lebowitz, L., Amidon, A., Lansiung, A. Maglione, M., Lang, A.J., Litz, B.T. (2012). Adaptive Disclosure: An open trial of a novel exposure-based intervention for service members with combat-related psychological stress injuries. Behavior Therapy, 43, 407-415. doi: 10.1016/j.beth.2011.09.001