Moral injury in relation to public debates: The role of societal misrecognition in moral conflict-colored trauma among soldiers

How do you see me? The impact of perceived societal recognition on PTSD symptoms amongst Norwegian peacekeepers

Background: The peacekeeper role is different to that of traditional combat, however, peacekeepers, like combat soldiers, may also be exposed to high levels of dangerous and/or potentially morally injurious events (PMIEs).Objective: It was hypothesized that given the centrality of societal approval for the peacekeeping mission, in addition to the known relevance of perceived social support, perceived societal recognition would influence PTSD symptoms (PTSS) and depression. It was hypothesized that perceived societal recognition would moderate the effect of exposure to potentially traumatic events and PMIEs on psychological outcomes.Method: 8341, predominantly male, former UNIFIL peacekeepers, almost three decades following deployment, answered a survey to determine the impact of perceived social support and perceived societal recognition, on PTSS and depression symptoms. Hierarchical regression analyses were performed for PTSS and depression separately and moderation analysis was performed for perceived societal recognition.Results: Exposure to potentially traumatic events showed the greatest predictive value for PTSS and exposure to PMIEs and potentially traumatic events were equally predictive of depression symptoms. While perceived social support presented the strongest buffer for PTSS and depression symptoms following UNIFIL deployment, perceived societal recognition also significantly contributed to the prediction of both PTSS and depression symptoms. There was a weak moderation effect of perceived societal recognition on trauma type in the development of PTSS.Conclusions: Even decades following peacekeeping deployment, military experiences have a significant impact on psychological functioning. This impact is both from the types of events experienced and from the perception of social and societal support upon return home.

"Ruptured selves: moral injury and wounded identity"

Moral injury is the trauma caused by violations of deeply held values and beliefs. This paper draws on relational philosophical anthropologies to develop the connection between moral injury and moral identity and to offer implications for moral repair, focusing particularly on healthcare professionals. We expound on the notion of moral identity as the relational and narrative constitution of the self. Moral identity is formed and forged in the context of communities and narrative and is necessary for providing a moral horizon against which to act. We then explore the relationship between moral injury and damaged moral identities. We describe how moral injury ruptures one's sense of self leading to moral disorientation. The article concludes with implications for moral repair. Since moral identity is relationally formed, moral repair is not primarily an individual task but requires the involvement of others to heal one's identity. The repair of moral injury requires the transformation of a moral identity in community.

‘Where am I in all of this?’ Impact of a morally injurious mission on the home front of Dutchbat III military Veterans

LAY SUMMARY

Research has shown time and time again that war has an impact on the mental well-being of Veterans and their families. But what does that impact look like when a mission is characterized by severe violations of norms and values (in other words, moral injury)? In this study, family members of Dutch Veterans talked about the impact on their lives of a mission gone bad in the former Yugoslavia, 25 years after it happened. Although most of the families were doing well, all of the families felt left alone in taking care of their Veterans after they returned and in dealing with negative press coverage. For the well-being of all, they expressed the need for more appreciation for and acknowledgement of Veterans and their families.

Caught between is and ought: The Moral Dissonance Model

Considerable academic effort has been invested in explaining the causes of, and processes behind moral injury. These efforts are mostly focused on assessment and treatment within a clinical setting. Collective and social factors contributing to moral injury are often overlooked in current literature. This perspective article considers the role of contextual factors associated with moral injury and proposes a framework that describes their relation to individual aspects. The resulting Moral Dissonance Model (MDM) draws on existing theories and frameworks. The MDM explains how dissonance can occur when the actual behavior-the response to a morally challenging situation-contradicts with morally desirable behavior. Individual and collective factors, which change over time, contribute to the experience of dissonance. The inability to sufficiently solve dissonance can lead to moral injury, but not as a matter of course. The MDM can help to understand the underlying processes of moral distress. It raises awareness of the influence of public debate and controversy, and the resulting changing societal attitudes over time. Its implications and future use are discussed.

Associations between psychosocial stressors at work and moral injury in frontline healthcare workers and leaders facing the COVID-19 pandemic in Quebec, Canada: A cross-sectional study

Healthcare workers (HCWs) on the frontline of the COVID-19 pandemic exhibit a high prevalence of depression and psychological distress. Moral injury (MI) can lead to such mental health problems. MI occurs when perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations. Since the start of the pandemic, psychosocial stressors at work (PSWs) might have been exacerbated, which might in turn have led to an increased risk of MI in HCWs. However, research into the associations between PSWs and MI is lacking. Considering these stressors are frequent and most of them are modifiable occupational risk factors, they may constitute promising prevention targets. This study aims to evaluate the associations between a set of PSWs and MI in HCWs during the third wave of the COVID-19 pandemic in Quebec, Canada. Furthermore, our study aims to explore potential differences between urban and non-urban regions. The sample of this study consisted of 572 HCWs and leaders from the Quebec province. Prevalence ratios (PR) of MI and their 95% confidence intervals (CI) were modelled using robust Poisson regressions. Several covariates were considered, including age, sex, gender, socio-economic indicators, and lifestyle factors. Results indicated HCWs exposed to PSWs were 2.22-5.58 times more likely to experience MI. Low ethical culture had the strongest association (PR: 5.58, 95% CI: 1.34-23.27), followed by low reward (PR: 4.43, 95% CI: 2.14-9.16) and high emotional demands (PR: 4.32, 95% CI: 1.89-9.88). Identifying predictors of MI could contribute to the reduction of mental health problems and the implementation of targeted interventions in urban and non-urban areas.

Why Conscience Matters: A Theory of Conscience and Its Relevance to Conscientious Objection in Medicine

Conscience is an idea that has significant currency in liberal democratic societies. Yet contemporary moral philosophical scholarship on conscience is surprisingly sparse. This paper seeks to offer a rigorous philosophical account of the role of conscience in moral life with a view to informing debates about the ethics of conscientious objection in medicine. I argue that conscience is concerned with a commitment to moral integrity and that restrictions on freedom of conscience prevent agents from living a moral life. In section one I argue that conscience is a principle of moral awareness in rational agents, and that it yields an awareness of the personal nature of moral obligation. Conscience also monitors the coherence between an agent's identity-conferring beliefs and intentions and their practical actions. In section two I consider how human beings are harmed when they are forced to violate their conscience. Restrictions on the exercise of conscience prevent people from living in accord with their own considered understanding of the requirements of morality and undermine one's capacity for moral agency. This article concludes with a consideration of how a robust theory of conscience can inform our understanding of conscientious objection in medicine. I argue that it is in the interest of individual practitioners and the medical profession generally to foster moral agency among doctors. This provides a prima facie justification for permitting at least some kinds of conscientious objection.

Relating to moral injuries: Dutch mental health practitioners on moral injury among military and police workers

In recent years the concept of moral injury has become a common term to describe the lasting impact of moral transgressions on frontline workers. This article aims to broaden the largely clinical debate by involving the views of a diverse group of mental health practitioners who support military and police personnel in the Netherlands. These practitioners are chaplains, confidential counsellors, social workers, psychologists and integrity officers. How do these practitioners describe the moral injuries of servicemen and police officers and how do they think these should be approached? Through interviews with thirty different practitioners this study shows that definitions of moral injuries diverge considerably. In addition, the article analyses six different approaches to moral injuries. These range from framing moral injury as an exceptional problem that requires specific expertise, to seeing it as a broad issue that places workers in a larger moral community. An analysis of this variety both serves as an indication of possible ways to deal with moral injuries, and as a basis for a critical reflection on the implications of various approaches.

Encountering children and child soldiers during military deployments: the impact and implications for moral injury

Background: During a deployment, soldiers must make seemingly impossible decisions, including having to engage with child soldiers. Such moral conflicts may continue to affect service members and veterans in the aftermath of a deployment, sometimes leading to severe moral distress, anguish, and personal crises. Service providers have increasingly argued that as a diagnosis, Post-Traumatic Stress Disorder (PTSD) cannot account for these deeply personal and painful moral conflicts. In light of this, the concept of moral injury has been introduced to better capture the profound forms of guilt and shame that may be experienced by service members and veterans. Objective: This paper addresses encounters with children and child soldiers during military deployments, as well as the risk for moral injury during and following these encounters, and their implications. This exploratory paper brings together existing literature on the topic to introduce, illustrate, and offer potential and promising interventions. Results: Given the potential moral conflicts that may ensue, military personnel who encounter child soldiers during a military deployment may be at risk for moral injury during and following these encounters. The introduction of the concept of moral injury provides a way for these largely unnamed personal and painful moral conflicts and violations to be recognized, addressed, and with appropriate care, remedied. Although there is limited research into their effectiveness at treating moral injury, individual and group-based interventions have been identified as potentially beneficial. Conclusion: As encounters with children during deployments are likely to continue, systematic research, training, healing interventions and prevention strategies are vital to support and protect children in conflict settings, as well as to ensure the mental health and well-being of service members and veterans. HIGHLIGHTS Profound moral conflicts may affect service members and veterans in the aftermath of a military deployment, sometimes leading to severe moral distress, anguish, and personal crises. The concept of moral injury has been introduced to better capture the profound forms of guilt and shame that may be experienced by service members and veterans.Encountering children and child soldiers during a military deployment, may present unique challenges, stress, and moral crises leading to potentially moral injurious events. In particular, transgression-based events which result from an individual perpetrating or engaging in acts that contravene his or her deeply held moral beliefs and expectations such as harming children, and betrayal-based events, which results from witnessing or falling victim to the perceived moral transgressions of others, may lead to lasting psychological, biological, spiritual, behavioural and social impairments.Interventions applied in both an individual-based context such as Cognitive Processing Therapy, Impact of Killing, Adaptive Disclosure, and a group-based context such as Acceptance and Commitment Therapy and Resilience Strength Training, have been identified as potentially beneficial to addressing moral injury. However, more research is required to ascertain appropriate and effective intervention and healing strategies.

Moral Injury in Trauma-Exposed, Treatment-Seeking Police Officers and Military Veterans: Latent Class Analysis

Exposure to morally injurious events may have a severe, prolonged negative impact on psychosocial functioning, known as moral injury (MI). Research into the prevalence of MI has mostly focused on event exposure rather than on psychosocial impact. Also, the relationship between MI and post-traumatic stress disorder (PTSD) remains a matter of interest. The aim of this study was to identify MI and PTSD symptom profiles among trauma-exposed, treatment-seeking police officers and military veterans, and to explore demographic and clinical differences between symptom profiles. Latent class and multinomial regression analyses were conducted in a sample of 1,703 participants, using the Clinician-Administered PTSD Scale for DSM-5 and the Brief Symptom Inventory. Four classes of participants were identified, labeled as a MI class (n = 192; 11.27%), a MI-PTSD class (n = 565; 33.18%), a PTSD class (n = 644; 37.82%), and a Neither MI-nor PTSD class (n = 302; 17.73%), resulting in 44.45% (n = 757) of participants who met an MI symptom profile with or without PTSD. There were significant differences between the classes in terms of gender as well as PTSD and comorbid psychopathology symptom severity, the latter of which was highest in the MI-PTSD class. In conclusion, a substantial subgroup of trauma-exposed, treatment-seeking police officers and military veterans could be classified as suffering from MI. Routinely screening for MI in treatment-seeking police officers and military veterans is recommended, and interventions aimed at relieving MI in these populations may be indicated.

Research-based Theatre about veterans transitioning home: A mixed-methods evaluation of audience impacts

RATIONALE

Contact!Unload, a research-based theatre production, portrays veterans experiencing mental health challenges and overcoming them through therapeutic enactment. It was performed eight times by veteran performers in 2017 for audiences in two Canadian cities comprised of civilians and military-connected personnel and their families (n = 525).

METHODS

Drawing upon qualitative and quantitative data sources, this paper evaluates the immediate and longer-term impacts of Contact!Unload as a knowledge translation intervention for audience members.

RESULTS

Our findings suggest that the performance: 1) improved knowledge of mental health concerns and symptoms that some veterans experience when transitioning to civilian life, 2) increased knowledge of the need for mental health supports and care for veterans, 3) sustained impacts on awareness and knowledge six months after the play and 4) sparked dialogue and actions after the show for some audience members. Moreover, theatre was seen as a powerful medium to engage audience members both cognitively and affectively in the topic.

CONCLUSIONS

Research-based theatre has significant potential as a knowledge translation intervention for mental health topics. The work also points to the untapped potential of using RbT to engage audience members in a mental health literacy intervention. Future work is needed to study how to effectively combine research-based theatre with intervention design frameworks and other mental health literacy interventions.

Social Embeddedness of Firefighters, Paramedics, Specialized Nurses, Police Officers, and Military Personnel: Systematic Review in Relation to the Risk of Traumatization

Background: Firefighters, paramedics, specialized nurses working in Intensive Care Units (ICUs), Operating Rooms (OR), and Emergency Rooms (ER), police officers and military personnel are more frequently exposed to potentially traumatic events than the general population; they are considered high-risk professionals. To reduce the risk of traumatization it is of great importance to be embedded in a social environment with supportive relationships. Methods: We performed a systematic review (based on the PRISMA-Guidelines) looking for social connections within the environment in which high-risk professionals are embedded (work, home, community), to obtain evidence on the impact of these connections on the risk of traumatization. Additionally, we aim to identify relevant supportive relationships in the professionals' environments. We identified the relevant scientific literature by searching, without time, and language restriction, five electronic bibliographic databases: MEDLINE, PsycINFO, Sociological Abstracts, CINAHL, and Web of Science. These databases were last searched in January 2019. Results: A qualitative analysis of the 89 eligible (out of 9,047 screened) studies shows that for firefighters, paramedics, and emergency nurses social connections in their work environment are predominantly supportive relationships and may protect them against traumatization. In other occupations (OR-nurses, ICU-nurses, police officers), however, social connections at work are not only a source of support but are also a source of stress. For military personnel study results are inconclusive as to whether their social connections at work or at home support them against traumatization. In so far as connections are supportive, their sources vary greatly from one occupational group to another; they differ between work vs. home as well as within work between peers vs. supervisor. Conclusions: Being embedded in a social environment, i.e., having social connections, is important but not always sufficient to protect high-risk professionals against traumatization. For, while these connections may be the antecedents of supportive relationships, they can also be the antecedents of damaging relationships. Additionally, the sources of supportive relationships differ among groups. This suggests that knowledge of how the social structures of the occupational groups differ may increase our understanding of the impact of social connections and relationships, including socialization, on the risk of traumatization of high-risk professionals.

The Context-Variable Self and Autonomy: Exploring Surveillance Experience, (Mis)recognition, and Action at Airport Security Checkpoints

This paper critiques and extends the notion of autonomy by examining how common autonomy definitions construct selfhood, with the support of an analysis of airport surveillance experiences. In psychology, autonomy is (1) often oriented around volition and action rather than the-self-that-acts and (2) the-self-that-acts is construed in singular terms. This neglects the multiple, context-variable self: while others may confirm our self-definitions (recognition), identity claims may also be rejected (misrecognition). The autonomy critique is sustained through an ethnographic analysis of airport security accounts (N = 156) in multiple nations with comparable security procedure (e.g., identification checks, luggage screening, questioning). Such procedures position people in multiple ways (e.g., as safe/dangerous, human/object, respectable/trash). Where respondents felt recognized, they experienced the security procedures positively, actively assisted in the screening process (engaged participation), and did not adapt their behaviors. Where respondents felt misrecognized, they experienced surveillance negatively, were alienated, and responded by either accommodating their behavior to avoid scrutiny, seeking to disrupt the process, or else withdrawing from screening sites. In misrecognition, the strategies that are open to the subject are incompatible with autonomy, if autonomy is defined solely in terms of volition. Accordingly, the concept of autonomy needs to be analyzed on two levels: in terms of the subject's ability freely to determine their own sense of self, as well as the actor's ability freely to enact selfhood.