Impact of moral injury on the lives of UK military veterans: a pilot study

Professionals' perspectives on relevant approaches to psychological care in moral injury: A qualitative study

OBJECTIVES

Despite the increasing consensus that moral injury (MI) is a unique type of psychological stressor, there is an ongoing debate about best practices for psychological care. This qualitative study explored the perceptions of UK and US professionals in the field of MI investigating advances and challenges in treatment or support delivery and issues relating to treatment/support feasibility and acceptability.

METHODS

15 professionals were recruited. Semi-structured, telephone/online interviews were carried out, and transcripts were analyzed using thematic analysis.

RESULTS

Two interconnected themes emerged: perceived barriers to appropriate care for MI cases and recommendations for providing effective care to MI patients. Professionals highlighted the challenges that occur due to the lack of empirical experience with MI, the negligence of patients' unique individual needs and the inflexibility in existing manualised treatments.

CONCLUSIONS

These findings illustrate the need to evaluate the effectiveness of current approaches and explore alternative pathways, which will effectively support MI patients in the long-term. Key recommendations include the use of therapeutic techniques which lead to a personalised and flexible support plan to meet patients' needs, increase self-compassion and encourage patients to reconnect with their social networks. Interdisciplinary collaborations (e.g., religious/spiritual figures), could be a valuable addition following patients' agreement.

Conceptualization of moral injury: A socio-cognitive perspective

LAY SUMMARY

This article looks at how moral injury (MI) may develop by considering what event features may be especially salient and cause MI and what experiences an individual may have after an event that might lead to the occurrence of a MI. It proposes that the beliefs someone has about themselves, others, and the world can be shaped by experiences in childhood and early life. Once an individual has experienced a potentially morally injurious event (PMIE) — for example, witnessing something that violates deeply held moral or ethical codes but being unable to stop it, doing something that violates these ethical codes, or experiencing a significant betrayal — they may try to make sense of it by changing the way they see the world, themselves, and others. This can lead to problems in the individual’s relationship with themselves and others, leading to feelings of shame and guilt and withdrawal from other people. More important, for an event to be a PMIE, it must significantly challenge strongly held moral beliefs and a sense of right and wrong.

ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) in treatment seeking veterans: risk factors and comorbidity

PURPOSE

Emerging evidence suggests that ICD-11 CPTSD is a more common condition than PTSD in treatment seeking samples although no study has explored risk factors and comorbidities of PTSD and CPTSD in veteran populations. In this study, risk factors and comorbidity between veterans meeting criteria for PTSD or CPTSD using the ICD-11 International Trauma Questionnaire (ITQ) were explored.

METHODS

A sample of help-seeking veterans who had been diagnosed with a mental health difficulty (n = 177) was recruited. Participants completed a range of mental health and functioning measures. Multinomial logistic regression analysis was conducted to explore differences in the above factors between participants meeting case criteria for PTSD, CPTSD or another mental health disorder.

RESULTS

Those with CPTSD appeared to have taken longer to seek help, reported higher rates of childhood adversity and more experiences of emotional or physical bullying during their military careers. Further, participants with CPTSD reported a greater burden of comorbid mental health difficulties including high levels of dissociation, anger, difficulties related to moral injury and common mental health difficulties and greater degree of impairment including social isolation, sleep difficulties and impaired functioning.

CONCLUSIONS

Considering that CPTSD is a more debilitating condition than PTSD, there is now an urgent need to test the effectiveness of new and existing interventions in veterans with CPTSD.

The impact of moral injury on the wellbeing of UK military veterans

BACKGROUND

Experiences of potentially morally injurious events (PMIEs) have been found to negatively impact the mental health of US personnel/veterans, yet little is known about the effect of PMIEs on the mental health of the UK Armed Forces (AF). This cross-sectional study aimed to examine the association between PMIEs and the mental health outcomes of UK AF veterans.

METHOD

Assessments of PMIE exposure and self-report measures of common mental disorders were administered using an online questionnaire to 204 UK veterans. Subjects were classified as having experienced a morally injurious event (n = 66), a non-morally injurious traumatic event (n = 57), a 'mixed' event (n = 31), or no event (n = 50).

RESULTS

Potentially morally injurious experiences were associated with adverse mental health outcomes, including likely anxiety disorders and suicidal ideation, compared to those who reported no event exposure. The likelihood of meeting criteria for probable PTSD was greatest in those who had experienced a non-morally injurious trauma. No statistically significant association between alcohol misuse and experiencing a PMIE or traumatic event was observed.

CONCLUSIONS

The results provide preliminary evidence that potentially morally injurious experiences are associated with adverse mental health outcomes in UK AF veterans. Further work is needed to better understand the interplay between morally injurious events and threat-based trauma in order to design effective pathways for prevention and intervention for people exposed to highly challenging events.

Family and occupational functioning following military trauma exposure and moral injury

INTRODUCTION

Evidence is growing regarding the impact of potentially morally injurious events (PMIEs) on mental health; yet how moral injury may affect an individual's occupational and familial functioning remains poorly understood.

METHOD

Thirty male veterans who reported exposure to either traumatic or morally injurious events and 15 clinicians were recruited for semi-structured qualitative interviews.

RESULTS

While many veterans experienced psychological distress postevent, those who experienced PMIEs especially reported social withdrawal and engagement in aggressive, risk-taking behaviours. This was highly distressing for family members and created a tense, volatile home and workplace environment that was difficult for others to navigate. Following PMIEs, employment could be used as a cognitive avoidance strategy or as a means to atone for transgressive acts. In cases of moral injury, clinicians considered that targeted support for spouses and accessible guidance to help children to better understand how their military parent may be feeling would be beneficial.

CONCLUSIONS

This study provides some of the first evidence of the pervasive negative impact of PMIEs on veterans' familial and occupational functioning. These findings highlight the need to comprehensively screen for the impact of moral injury on daily functioning in future studies that goes beyond just an assessment of psychological symptoms.

Healthcare Workers and COVID-19-Related Moral Injury: An Interpersonally-Focused Approach Informed by PTSD

The COVID-19 pandemic has resulted in a still-unfolding series of novel, potentially traumatic moral and ethical challenges that place many healthcare workers at risk of developing moral injury. Moral injury is a type of psychological response that may arise when one transgresses or witnesses another transgress deeply held moral values, or when one feels that an individual or institution that has a duty to provide care has failed to do so. Despite knowledge of this widespread exposure, to date, empirical data are scarce as to how to prevent and, where necessary, treat COVID-19-related moral injury in healthcare workers. Given the relation between moral injury and post-traumatic stress disorder (PTSD), we point here to social and interpersonal factors as critical moderators of PTSD symptomology and consider how this knowledge may translate to interventions for COVID-19-related moral injury. Specifically, we first review alterations in social cognitive functioning observed among individuals with PTSD that may give rise to interpersonal difficulties. Drawing on Nietlisbach and Maercker's 2009 work on interpersonal factors relevant to survivors of trauma with PTSD, we then review the role of perceived social support, social acknowledgment and social exclusion in relation to potential areas of targeted intervention for COVID-19-related moral injury in healthcare workers. Finally, building on existing literature (e.g., Phoenix Australia-Centre for Posttraumatic Mental Health and the Canadian Centre of Excellence-PTSD, 2020) we conclude with individual and organizational considerations to bolster against the development of moral injury in healthcare workers during the pandemic.