On The Frontlines Of American
On the frontlines of American conflict stands a highly trained, efficient, and indispensable group of men and women that have dedicated their lives to the service and protection of our country. It is well documented that soldiers across many generations have fought tirelessly in an effort to preserve the American sense of freedom (Fischer et al, 2007). What many are unaware of, however, is that the adversity faced by our service people extends well beyond the scope of the battlefield. Mental health is an omnipresent concern of active duty, reserve, and veteran populations. These groups are susceptible to a broad spectrum of ailments including but not limited to depression, stress disorders, anxiety, post-traumatic stress disorder, and even suicidality due to their elevated exposure to high stress environments and traumatic events (Hoge et al, 2006). As research continues to illuminate the origination, symptoms, and prognosis of war related disorders, necessity has forced us to broaden our understanding in an effort to consider components of mental health that had previously been ignored (Hankin et al, 1999). One of these major components is the ethical and moral values a soldier may be forced to compromise in the line of duty resulting in a recently outlined phenomenon known as Moral Injury.
Moral Injury has been defined as an act of serious transgression that leads to inner conflict because it is at odds with the core ethical and moral beliefs of a person (Maguen et al, 2012). While comparable to PTSD, Moral Injury is not adequately covered by the diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Morally Injurious experiences create an array of psychological, spiritual, social, and behavioral problems that foster internal dissonance and conflict (Dresher et al, 2011). A major component of Moral Injury is, “the inability of a person to contextualize or justify personal actions or the actions of others and the unsuccessful accommodation of these experiences into pre-existing moral schemas resulting in shame, guilt, and withdraw” (Litz, 2009). Being a relatively new area of study, Moral Injury will require more research to delineate boundary conditions and symptom parameters, but it is now clear that this disorder is affecting many men and women across all branches of military and beyond. The focus of Moral Injury therefore lies with the development of more efficacious treatments based on all encompassing qualitative and quantitative studies. The wealth of available knowledge on this subject is limited, but several key elements hold consistent. These themes are the principal causation of the disorder, the differentiation of Moral Injury from like disorders, ethical and spiritual components of Moral Injury, currently available treatments, and the future of research and treatment. This critical review will focus on these themes as they appear throughout current studies and the strengths and limitations of these study conclusions.
Simply stated, Moral Injury is a serious internal conflict caused by an act (or the witnessing of an act) that is at odds with the core ethical and moral beliefs of a person resulting in profound shame or guilt (Maguen et al, 2012). The occurrence of these acts has become ever more common with the changes in military tactics stemming from technological advancements, and the nature of war in today’s world (Butler, 2007). The uncommon features of today’s wars include such things as guerilla warfare, counter insurgency, unmarked enemies, civilian threats, improvised explosive devices, and greater risk for harming non-combatant personnel (Litz, 2009). These elements of modern warfare create greater uncertainty, greater danger, and as a result, higher rates of Moral Injury. Soldiers are forced to carry out acts that violate previously deep held beliefs about maintaining a shared moral covenant, causing a loss of trust in not only the deteriorating world around them but also within themselves.
Part of what makes Moral Injury so devastating is the trust issues, the spiritual and existential dilemmas, psychological problems, and self-deprecation that are derived from the negation of moral expectations (Nash et al, 2013). Moral beliefs and values, like many of our cognitive schemas, develop slowly over the course of our lives throughout a ceaseless cycle of assimilation and reconciliation (Nash et al, 2013). The instantaneous tearing down of these intrinsic core understandings is the basis behind the many internal conflicts caused by moral injury. This premise also serves as the explanation for why there is no threshold for establishing the presence of moral injury (Maguen et al, 2012). A veteran may have no manifestations of the disorder or they might present with extreme symptoms. The severity of the disorder is entirely dependent on the history of the individual under consideration and his personal internalization of traumatic events juxtaposed against his pre-established schemas.
Experiences such as betrayal, disproportionate violence, incidents involving civilian casualties, and within rank violence seem to correlate more frequently with Moral Injury than do other events (Maguen et al, 2012). This is explained by the recurring theme that Moral Injury derives from challenges to one’s basic sense of humanity (Nash et al, 2013). It becomes clear then, how betrayal for example, may contradict a person’s expectation of human behavior and lead to traumatizing internal conflictions. The same holds true for civilian deaths, extreme and unnecessary violence, and inter-rank violence, all which belie internalized constructs of truth and challenge a person’s capacity to overcome fear and pain. Not everyone is able to withstand the trauma they witness, and as a result the effects of Moral Injury may begin to manifest.
The belief that one’s morals and values no longer fit within a civilian realm can have long lasting and dangerous mental health implications. Veterans and service people afflicted with Moral Injury often manifest their disorder through -handicapping, anger, and demoralization (Kopacz et al, 2015). Described as a “syndrome of shame,” Moral Injury can also lead to life threatening consequences such as self-harm and even suicidality (Bryan, 2014). There are three major factors that might lead someone to view suicide as the only alternative: feeling that one does not belong with other people, feeling that one is a burden to others or society as a whole, or an inability to overcome extreme exposure to pain and fear. (Maguen et al, 2012). Without treatment moral injury has the potential to direct many people down this path.
The element of fear is an important characteristic that differentiates the disorders under consideration. The presence or absence of fear is not a determining factor for the occurrence of a morally injurious experience. Moral Injury can occur without the clear possibility of physical injury or death as well as within the context of life threatening stressors that have historically provided the basis for PTSD (Currier et al, 2014). The distinction between fear and transgression is paramount to understanding the individual natures of PTSD and Moral Injury.
Several studies have been carried out within military populations to assess the necessity of a separation between PTSD and Moral Injury. One such study utilized a transcribed questionnaire and determined overwhelmingly that Moral Injury is not adequately covered within the diagnostic criteria of PTSD and that a clear divergence of the two disorders would be beneficial (Dresher et al, 2011). Many veterans concluded that there are uniquely identifiable morally injurious experiences in war that have the potential to create an array of psychological, social, behavioral, and spiritual problems independent of PTSD (Dresher et al, 2011). It was also brought to light however, that most veterans deemed the current definition of moral injury “inadequate, and in need of adjustment so as to be more easily understood. From this study and others, it is known that Moral Injury does indeed increase the risk of PTSD diagnosis among active duty military personnel and veterans (Dresher et al, 2011). Although this research provided a valuable perspective on the necessity of Moral Injury as its own entity, it became clear through many interviews that more research is needed to delineate the boundary conditions and symptoms parameters of Moral Injury (Dresher et al, 2011).
An amassing base of empirical findings suggests that spirituality can factor prominently into service member’s experiences of Moral Injury. Most notably, research has documented that internal confliction with self-forgiveness as well as the apprehension of being forgiven by God has been frequently associated with worse mental health symptoms (Kopacz et al, 2015). Moral Injury relates to deeply held beliefs about our own (or another’s) ability to maintain a shared moral covenant. Spirituality is crucial to this concept play because it drastically effects the creation and perception of the aforementioned covenant (Fontana et al, 2004). Dissonance and conflict are therefore more likely to occur in a person who holds his or her relationship with fellow humans to a heightened state (Kopacz et al, 2015). This person would also be more likely to experience violations to his or her beliefs about right, wrong, and personal goodness (especially in a combat setting). These perspectives may then lead to an inability to contextualize personal actions and eventually dysfunctional behaviors.
This study’s argument is not predicated on the idea that spirituality is bad, but rather that spirituality has the potential to create stricter moral standards that are more frequently transgressed than the comparatively lax standards of another less virtuous individual. Spirituality plays a major role in the development of cognitive schemas over a lifetime. These schemas define our personal ethical and moral beliefs as well as our perceptions of morality (Litz, 2009). The stronger these schemas have grown over time the more debilitating Moral Injury can prove to be. It has been shown in several studies that certain individuals may actually benefit from a sense of spirituality during the course of their rehabilitation (Kopacz et al, 2015), but the nature of these experiences makes results difficult to quantify.
Knowledge Gaps & Moving Forward:
Before any public health or military professional could hope to create new policy or programming to address Moral Injury for active duty military personnel or veterans, diagnosis and treatment needs to be attended to. Many elements of Moral Injury are still under debate by experts of the field, and the necessity for efficacious treatments remains an uncontested notion. As Moral Injury has only differentiated itself from similar mental health disorders in the past decade, many treatments are outdated and unlikely to be tailored to the individualistic needs of patients. Also, many treatment protocols still closely resemble those utilized in PTSD patients due to the similar nature of the disorders. If Moral Injury should continue to emerge as a separate entity from PTSD and other psychological disorders, new treatments must focus on being in tune with the etiology of the disorder as well as the rehabilitation of personal morality.
There is need for two major qualitative research themes addressed in treatment: the first is the reestablishment of trust. This includes but is not limited to the trust of one’s comrades, one’s self, and even of humanity as a whole. It is the loss of this trust that often forms the foundation on which Moral Injury can develop. Therefore, the first step in any successful treatment program should focus on the recreation of inter and intrapersonal trusting relationships (Kopacz et al, 2015). The second indispensable element of treatment is blame. Assigning blame for the occurrence of a Morally Injurious experience is an important coping mechanism. Understanding that an act was committed out of necessity (rather than out of the deterioration of human nature as a whole) can restore a person’s faith. If a violent transgression is witnessed, the ability to attribute that act to a specific person or group also aids in the forgiveness process (Kopacz et al, 2015). Once trust is reestablished and blame is assigned (or at least understood), real recovery can begin.
Several therapeutic alternatives do exist for veterans suffering from the effects of service-related psychological disorders including adaptive disclosure and cognitive processing therapy. Adaptive Disclosure is a 6-8-session intervention training technique that incorporates imaginal exposure exercises to facilitate processing of psychological, behavioral, and spiritual consequences of traumatic military experiences (Kopacz et al, 2015, Dresher et al, 2011). Cognitive processing therapy applies cognitive reappraisal skills to develop a new personal meaning associated with trauma (Kopacz et al, 2015). Both of these treatments have their merits, but they were initially developed for PTSD patients and lack the specificity necessary for Moral Injury care. They do present a sufficient starting point for how treating Moral Injury might be addressed. Some other potential alternatives are pastoral care, which incorporates a religious element into the treatment of a care seeker and may achieve the fulfillment left unsatisfied by other available alternatives, and Eye Movement Desensitization and Reprocessing (EMDR), which is a form of psychotherapy designed to help alleviate the symptoms of emotionally traumatic events (Dresher et al, 2011). One exciting, but underdeveloped, potential line of research public health and military professionals should pursue is the identification of biomarkers associated with Moral Injury in military personal prior to the onset of a disorder (Kopacz et al, 2015). Treatment for Moral Injury does exist but practical alternatives are either not tailored directly to Moral Injury patients or remain in their infancy. The future of research in this field must be directed toward both qualitative and quantitative data collection and developing viable treatment alternatives in order to restore afflicted veterans to a state of mental health equilibrium.
It is clear that our understanding and treatment of Moral Injury in veteran populations remains profoundly underdeveloped. However, as Moral Injury continues its divergence away from similar trauma-related disorders such as PTSD, it will receive more attention from relevant parties and the amount of available information will likely grow exponentially. The current wealth of knowledge on the subject has already provided the foundation for further exploration. Firstly, it has been expressed in military populations that the current definition of Moral Injury should be adjusted so as to be less ambiguous and better understood by veterans. It has also been recommended that the parameters, boundary conditions, and symptoms of Moral Injury be more expressly delineated as separate from PTSD because there is sufficient evidence to continue viewing the two disorders as separate entities. These two changes to Moral Injury study could be simply addressed by the VA and other public health professionals with a minimal time and economic commitment.
Further research should be conducted in regards to the family members of victims in an effort to aid in coping and treatment as well as to avoid the potential for empathetic internalization, which could lead to vicarious traumatization (Nash et al, 2013). A statistical analysis of military populations could also quantify the problem and draw more attention to the field as a whole. Most importantly, however, is the development of viable treatment alternatives. Self-harm and suicidality have been associated with Moral Injury in severe cases. The prevention of these events as well as the reduction of stigmatization, and the elimination of fear and pain in victims should be the ultimate goal of all future research in the field of Moral Injury (Greene et al, 2007). There also exists the possibility that members of military populations would be unwilling to admit their emotional turmoil as a result of the battle hardened demeanor that has been instilled in them through the course of their training and service. This could result in an under representation of Moral Injury within the considered population.
Another study addressing the gaps in Moral Injury literature would likely draw nearly identical conclusions due to the consistent nature of many studies as well as the narrow span of available research on the topic; the field of available research is limited to the extent that no conclusive evidence regarding effectiveness of treatments was available. As previously stated, certain articles suggested using similar techniques as those used in PTSD treatment, but these efforts were not supported by any significant data. This remains a disappointing shortcoming for military and veteran’s health, but it underlines the necessity that for future research, treatment should be the focal point of Moral Injury studies (Worthington et al).
Policy and Program Creation:
After identifying gaps in the knowledge of this emerging categorization of mental health disorder, public health professionals and the VA can work together to create new policy and programming to minimize the prevalence, and potentially to minimize the exposure, to the triggers for Moral Injury. The continuing war on terrorism has exposed our country’s military personnel to unprecedented levels of psychological harm (Stern, 2014). As the diagnosis and treatment for PTSD continues to improve, more active duty military personnel and veterans have been seeking treatment, and as the definition of Moral Injury becomes more clear, the VA may not have the resources to adequately address all these issues. There are some factors of our current defense policies that may be increasing the exposure to events that lead to psychological trauma. Asking questions about the effectiveness of these policies and addressing the factors are a potential way to alleviate mental health stressors. As Moral Injury can be a precursor for, or exist in conjunction with, PTSD (and other psychological disorders) policy change could have an effect on the way the military and the VA views mental health as a whole.
The first defense policy that should be examined is the Longer deployment further apart for people with families. Is it worse to come home and then go back?
The analysis of the policy requires us to create a course of action for mental health for soldiers and veterans. Beginning just over a decade ago, the US military began conducting population-level screening for mental health issues among service members returning from deployment; screening continued at regular intervals for 1 year after deployment (Hoge et al, 2006). The main goal of these “post-deployment health assessments (PDHA)” was to screen for physical exposures to environmental and occupational health threats, PTSD, major depression, and the use of military health care services. For some branches of the military, the PDHA is not required unless a pre-deployment health assessment was completed; those are usually only required for EOH exposures at the command of a superior. Until an independent study intervened in 2006, the US military had not completed any analysis of results from the program, and there is currently no evidence that analysis has continued after the independent study (Hoge et al, 2006). The military has an excellent window of opportunity to improve mental health issues that they are not currently taking advantage of.
The pre and post-deployment health assessments should place a greater emphasis on mental health, particularly for PTSD, depression, and, as it continues to emerge, Moral Injury. The assessments need to be simple, yet detailed and comprehensive, and they should take place with a health care professional in person rather than through training or online form self-assessment. Mental health is a delicate issue, and these assessments demand a delicate balance of illuminating, but un-intrusive, questions. In an ideal world, every service member would be required to complete a pre and post-deployment health assessment with analysis from a psychiatrist or psychologist, but the funding necessary for the endeavor would be extraordinary. Completing the assessments with public health professionals, however, is one potential course of action. Throughout the assessment screening process, post-deployment in particular, these professionals would have the opportunity to individually evaluate service members, “flag” the ones that show signs of mental health issues and send them up the chain to more qualified health professionals for further analysis and treatment. Service members who are flagged could be those with pre-existing conditions or family history of mental illness, those who have been exposed to killing, torture, or other severe trauma, or simply those who wish to report a mental health issue of their own volition.
The existing assessments are already funded by the military with US tax dollars, but a continuation of screening and treatment for those “flagged” individuals and veterans after the 1-year mark would require intervention from the VA and other stakeholders. Lower-bound health care for combat-induced PTSD for Iraq and Afghanistan veterans has been estimated to cost between $1.5 and $2.7 billion (Cesur, Sabia, & Tekin, 2013). These numbers are astronomical, especially because Moral Injury is not yet factored into the estimates. It doesn’t stop at direct health care costs; lost work productivity also accounts for more than half the costs for PTSD and major depression (Cesur, Sabia, & Tekin, 2013). Assessments and treatments for “flagged” individuals could actually end up financing themselves as veterans could return to work and other medical costs would decrease (Stern, 2014). If existing funding is allocated to these changes and new research and treated veterans return to work, the total cost of a new assessment and treatment plan wouldn’t be as formidable as many believe it could be. When it comes to mental health, it is always easier to be asked if you need help than it is to ask for help yourself. Creating revised PDHAs for service members and new health assessments for veterans could be an avenue for public health professionals to help keep our military family safe for a change.
In conclusion, military and veteran populations will always be at an increased risk for mental health disorders such as Moral Injury due to their elevated exposure to high stress environments and traumatic events. While the literature remains inconclusive on several key components of the data, there is a sufficient wealth of knowledge to confirm that Moral Injury is an important mental disorder that affects many of our nation’s service people (Vargas et al, 2013). It can also be stated that several distinctive features of Moral Injury such as the etiology, ethics, morality, and spirituality differentiate the disorder from PTSD (Worthington, 2012). This clear separation should pave the way for further research and new policy and program creation dedicated to mental health and Moral Injury understanding, treatment, and prevention. Dedicating resources to the advancement of Moral Injury research should be fundamental to the scientific and military communities as it is essential to the treatment and rehabilitation of the men and women who risk their lives every day in defense of this country.