Moral injury and moral repair in war veterans: A preliminary model and intervention strategy

National Center for PTSD, VA Boston Healthcare System, United States.
Clinical psychology review (Impact Factor: 7.18). 08/2009; 29(8):695-706. DOI: 10.1016/j.cpr.2009.07.003
Source: PubMed


Throughout history, warriors have been confronted with moral and ethical challenges and modern unconventional and guerilla wars amplify these challenges. Potentially morally injurious events, such as perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long-term, emotionally, psychologically, behaviorally, spiritually, and socially (what we label as moral injury). Although there has been some research on the consequences of unnecessary acts of violence in war zones, the lasting impact of morally injurious experience in war remains chiefly unaddressed. To stimulate a critical examination of moral injury, we review the available literature, define terms, and offer a working conceptual framework and a set of intervention strategies designed to repair moral injury.

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    • "to SI above and beyond other types of combat. Our findings resonate with the construct of " moral injury, " which has been described as " perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations " (Litz et al., 2009, p. 697), a definition that would include attempting to kill or believing one has killed another human being. "
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    ABSTRACT: Objective: Combat veterans are at risk for several adverse outcomes such as posttraumatic stress disorder (PTSD), depression, hazardous alcohol use, and most critically, suicidal behaviors. The high rate of suicide in veterans has been understood as a correlate of PTSD and depression, but it is possible that certain specific types of combat experiences may lead to suicidal behaviors. Acts committed by veterans in the context of war such as killing may evoke a "moral injury," which leads to thoughts of ending one's life. Method: The present exploratory research examined relationships between combat experiences and suicidal ideation (SI) and PTSD in a sample of 68 Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) veterans (91% male, mean age = 32.31 years) who had screened positive for alcohol misuse. We examined firing a weapon/killing in combat (Firing/Killing) and killing in combat (Killing) alone as predictors of SI and PTSD severity in both the full sample and men only. Results: Firing/Killing were associated with SI for the full sample and men only, and Killing showed a trend toward significance in predicting SI. Hierarchical regression analyses suggested that Firing/Killing did not predict PTSD for the full sample or men only, but Killing was predictive of PTSD for both samples. Conclusions: These results indicate that there may be differences in Firing/Killing and Killing alone in OEF/OIF veterans who screened positive for alcohol misuse. Thorough screening of combat experiences and addressing moral injury in returning combat veterans may help reduce high rates of suicide and PTSD. (PsycINFO Database Record
    Psychological Trauma Theory Research Practice and Policy 10/2015; DOI:10.1037/tra0000085 · 2.31 Impact Factor
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    • "Moreover, they must often also behold the gruesome demise of the enemy, as they find themselves taking the role of the perpetrator , engaged in the aggressive and violent acts of killing. Furthermore, in the face of this reality, many soldiers may come to question whether they have betrayed " what's right " (Shay, 1994) in the process of fighting for their country, thus sustaining what has been termed moral injury (Litz et al., 2009; Shay, 2014;). Subsequent captivity then continues to drain the remaining vitality that the combatant has managed to retain, as it occurs after the soldier may be quite battered, tired, lethargic, and devoid of much of what has kept him going up to that point. "
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    ABSTRACT: As most research devoted to the aftermath of war captivity discusses physical and intrapersonal ramifications, the interpersonal domain is left largely underrepresented in research. Our aim in this chapter is to shed light on this realm of psychosocial deficit. Indeed, throughout this chapter we highlight the manner in which various dimensions of interpersonal pernicious and malicious conduct during captivity are weaved into a tapestry of dysfunctional interpersonal relationships in the life that is to come after repatriation. In order to accomplish this we first elaborate in some detail the ingenuity of torture and misconduct of war captivity. Next, we address multifarious dimensions of interpersonal disruption that POWs may undergo after repatriation. Throughout the chapter we provide findings from a longitudinal study that has examined such aspects in a prospective cohort of Israeli ex-POWs who fell captive in 1973 in Egypt and Syria. Concomitantly we survey various interpersonal aspects that include attachment injury, marital and familial adjustment, loneliness and betrayal following captivity. Once these dimensions of post-repatriation become evident, it is then simple to see the devastation that war captivity instills in concentric circles of interpersonal relationships: family, friend, society and state. It is from these realizations that we suggest directions for researchers, clinicians, and policy makers to work towards the mending of interpersonal bonds, the communalization of trauma, and reinstatement of trust. Hopefully with such efforts where detachment was, there attachment will once again be, and where loneliness reigned there connection will once again rule.
    Traumatic Stress and Long-Term Recovery: Coping with Disasters and Other Negative Life Events, Edited by Katie E. Cherry, 10/2015: chapter 7: pages 113-132; Springer., ISBN: 978-3-319-18865-2
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    • "Research linking spiritual distress with suicidal ideation among OIF veterans underscores the need for future research in this area (Maguen et al., 2011). Although consensus has not yet been reached on the precise nature of this phenomenon, some tools for assessing and addressing moral injury and broader spiritual struggles among veterans are emerging (e.g., Currier, Holland, Drescher, & Foy, 2015; Litz et al., 2009; Sherman, Harris, & Erbes, 2015). "
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    ABSTRACT: As the major ground troop presence in the Middle East is reduced, it is time to reflect, maximize lessons learned, and look forward to what lies ahead for the nearly 2.6 million service members of the United States military who have deployed in support of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn. A systematic review of the literature on postdeployment functioning of Iraq and Afghanistan troops was conducted. Findings are described and contextualized in terms of service members’ ongoing strengths, needs, and challenges. The corpus of research on deployed personnel indicates that service members demonstrate resilience in the face of war-related stressors. However, postdeployment impairment in 6 functional domains emerged in the literature review, including mental health, social and role functioning, relationship functioning and family life, spirituality, physical health, and financial well-being. Although risk factors and future trajectories vary across these domains, psychiatric difficulties are a consistent predictor of a worsened course. Implications for clinical practice are described based on the review findings. To promote wellbeing in the years ahead, it is important that service members are supported in their various roles (such as in the classroom, the workforce, and the family). In addition, routine assessment of functioning across domains is highly recommended for postdeployment service members.
    Professional Psychology Research and Practice 08/2015; 45(5):355-365. DOI:10.1037/pro0000043 · 1.34 Impact Factor
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