Self-Forgiveness and Military Service: Equipping Warriors to Combat Moral Injury

Abstract Background Our goal was to examine the association between moral injury, mental health, and suicide attempts during military service and after separation by gender in post-9/11 veterans. Methods A nationally representative sample of 14057 veterans completed a cross-sectional survey. To examine associations of exposure to potentially morally injurious events (PMIEs; witnessing, perpetrating, and betrayal) and suicidal self-directed violence, we estimated two series of multivariable logistic regressions stratified by gender, with peri- and post-military suicide attempt as the dependent variables. Results PMIE exposure accounted for additional risk of suicide attempt during and after military service after controlling for demographic and military characteristics, current mental health status, and pre-military history of suicidal ideation and attempt. Men who endorsed PMIE exposure by perpetration were 50% more likely to attempt suicide during service and twice as likely to attempt suicide after separating from service. Men who endorsed betrayal were nearly twice as likely to attempt suicide during service; however, this association attenuated to non-significance after separation in the fully adjusted models. In contrast, women who endorsed betrayal were over 50% more likely to attempt suicide during service and after separation; PMIE exposure by perpetration did not significantly predict suicide attempts before or after service among women in the fully adjusted models. Conclusions Our findings indicate that suicide assessment and prevention programs should consider the impact of moral injury and attend to gender differences in this risk factor in order to provide the most comprehensive care.

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Neurologist, Psychiatrist, 20 years’ experience, USA

Non-Epileptic Seizures in Our Experience ◽

10.1093/med/9780190927752.003.0048 ◽

2020 ◽

pp. 137-138

Author(s):

Markus Reuber ◽

Gregg H. Rawlings ◽

Steven C. Schachter

Keyword(s):

Military Personnel ◽

Military Service ◽

Epileptic Seizures ◽

Moral Injury ◽

Treatment Manual ◽

Substance Abuse Treatment Program ◽

Moral Beliefs ◽

Knowing That ◽

Core Issue ◽

Abuse Treatment

This chapter examines the case of a patient with psychogenic non-epileptic seizures (PNES) and moral injury (MI). Identified in some civilian and military personnel, MI occurs in people who commit, witness or fail to prevent acts that transgress deeply held moral beliefs. Since returning from military service, every time he picked up his little boy at home, the patient saw the child who unknowingly stepped out in front of his target, just before he pulled the trigger. He has been seen in the posttraumatic stress disorder clinic and the substance abuse treatment program, as well as groups for veterans who saw combat overseas. None of them have taken away the pain of the core issue: MI. The patient cannot get over the guilt and shame of what he did while deployed. Knowing that no pharmacological or neuromodulatory intervention or treatment manual can provide a cure for this scar makes one question what neurologists, psychiatrists, and therapists really have to offer.

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Moral Injury and Suicide Ideation Among Israeli Combat Veterans: The Contribution of Self-Forgiveness and Perceived Social Support

Journal of Interpersonal Violence ◽

10.1177/0886260520920865 ◽

2020 ◽

pp. 088626052092086

Author(s):

Yossi Levi-Belz ◽

Neta Dichter ◽

Gadi Zerach

Keyword(s):

Social Support ◽

Combat Veterans ◽

Suicide Ideation ◽

Perceived Social Support ◽

Protective Role ◽

Moral Injury ◽

Self Report ◽

Cross Sectional ◽

Self Forgiveness ◽

Cross Sectional Design

Modern warfare within a civilian setting may expose combatants to severe moral challenges. Whereas most of these challenges are handled effectively, some potentially morally injurious events (PMIEs) may have deleterious psychological, spiritual, and interpersonal effects among them, which may increase the risk for suicide ideation and behaviors (SIB). In this study, we aimed to examine the protective role of self-forgiveness and perceived social support on the relationship between exposure to PMIEs and SIB among combat veterans. A sample of 191 Israeli combat veterans completed validated self-report questionnaires in a cross-sectional design study, tapping moral injury, SIB, perceived social support, and self-forgiveness. Veterans with a history of SIB revealed higher levels of exposure to PMIEs and lower levels of self-forgiveness and perceived social support than veterans with no SIB history. Moreover, beyond the contributions of the PMIE dimensions, significant contributions of self-forgiveness and perceived social support to current suicide ideation (SI) were found. Importantly, the moderating model indicated that higher social support moderated the link between PMIEs and current SI. Based on the current findings, it can be suggested that self-forgiveness and perceived social support are important contributors to lower SI levels among veterans with PMIEs. It can be further suggested that interpersonal support may help veterans develop a sense of belongingness and bonding, which is a plausible basis for diminishing the risk of SI following PMIE exposure.

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Moral Injury as a Mediator of the Associations Between Sexual Harassment and Mental Health Symptoms and Substance Use Among Women Veterans

Journal of Interpersonal Violence ◽

10.1177/0886260520985485 ◽

2021 ◽

pp. 088626052098548

Author(s):

Hannah C. Hamrick ◽

Sarah J. Ehlke ◽

Rachel L. Davies ◽

Jennise M. Higgins ◽

Jennifer Naylor ◽

...

Keyword(s):

Mental Health ◽

Sexual Harassment ◽

Military Service ◽

Women Veterans ◽

Moral Injury ◽

Health Providers ◽

Mental Health Symptoms ◽

Convenience Sample ◽

Health Symptoms ◽

Military Members

Moral injury is an array of symptoms theorized to develop in response to morally injurious events, defined as events that challenge one’s core moral beliefs and expectations about the self, others, and world. Recent measures of moral injury have distinguished self-directed moral injury (e.g., moral injury symptoms that emerge following the perpetration of morally injurious events) from other-directed moral injury, the symptoms of which are believed to stem from one’s response to actions that others have committed (e.g., within-rank violence, failures of leadership, and acts of betrayal committed by trusted others or institutions). Using a convenience sample of 154 primarily former military women, the present study examined if other-directed moral injury symptoms (e.g., anger, betrayal, and mistrust) associated with military experience would mediate the association between military sexual harassment and mental health and substance abuse symptoms. Results demonstrated that 85.8% ( n = 127) of the of this sample of women veterans reported experiencing sexual harassment during their military service. Using a single mediation model, we further demonstrated that other-directed moral injury mediated the association between sexual harassment experience and mental health symptoms. Given the percentage of women veterans who reported sexual harassment, these results suggest that additional training for military members, and particularly, military leaders, is necessary to begin to reduce sexual harassment. In addition, mental health providers who work with current and former military members should consider how other-directed moral injury may be associated with mental health symptoms among women veterans who have experienced sexual harassment while in the military.

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Understanding the Impact and Treatment of Moral Injury Among Military Service Members

FOCUS The Journal of Lifelong Learning in Psychiatry ◽

10.1176/appi.focus.20170023 ◽

2017 ◽

Vol 15 (4) ◽

pp. 399-405 ◽

Cited By ~ 1

Author(s):

Philip Held ◽

Brian J. Klassen ◽

Alyson K. Zalta ◽

Mark H. Pollack

Keyword(s):

Military Service ◽

Moral Injury ◽

Service Members ◽

Military Service Members ◽

The Impact

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Moral Injury and Suicide Ideation Among Combat Veterans: The Role of Trauma-Related Shame and Collective Hatred

Journal of Interpersonal Violence ◽

10.1177/08862605211007932 ◽

2021 ◽

pp. 088626052110079

Author(s):

Gal Schwartz ◽

Eran Halperin ◽

Yossi Levi-Belz

Keyword(s):

Military Service ◽

Protective Factor ◽

Combat Veterans ◽

Suicide Ideation ◽

Mental Health Problems ◽

Moral Injury ◽

Self Report ◽

Cross Sectional ◽

Study Results

Exposure to potentially morally injurious events (PMIEs) among combat veterans has been acknowledged as a significant stressful combat event that may lead to mental health problems, including suicide ideation (SI). Several studies have examined the risk and protective factors that can explain the conditions in which PMIEs may contribute to the development and maintenance of SI. However, the contribution of social-emotional factors has yet to be examined. In the current study, we examined the association between PMIE-Self and SI among combat veterans and explored the mediating role of trauma-related shame and the moderation role of collective hatred in this association. A volunteer sample of 336 Israeli combat veterans was recruited, completing self-report questionnaires in a cross-sectional study. Results indicated that PMIE-Self was positively associated with SI, and trauma-related shame mediated this association. Moreover, collective hatred moderated both their direct (PMIE–SI) and indirect (PMIE–Shame–SI) association. Notably, collective hatred had an inverse role for each of the associations. Thus, collective hatred was found to comprise both a risk and a protective factor for SI following PMIE-Self. The current findings highlight the crucial contribution of trauma-related shame and collective hatred to the association between moral injury and suicidality. Moreover, the findings demonstrate that even years after their military service release, combat veterans exposed to PMIEs may still feel consumed by painful memories and maintain premonitions of a foreshortened future. Furthermore, the findings help to better understand the dynamics of collective hatred and the challenge of modifying it.

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