Moral injury – A war trauma affecting current and former military personnel

I commend Carta, Moro, and Bass (2014) on their recently published article ‘explor[ing] the theme of the traumatic consequences of war and its impact on mental health’. As briefly mentioned in their article, military personnel very often share the traumatic consequences of war. In recent years, attention has been particularly drawn to the experience of moral injury in current and former military personnel, especially as a potential risk factor for suicidal behavior in some Veteran populations (Maguen et al., 2012). Carta and colleagues very effectively highlight the many mental health challenges faced by civilian and refugee populations in times of war. Moral injury in military personnel should also warrant mention.

Moral injury is conceptualized as ‘perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations’ (Litz et al., 2009). In addition to life-threatening situations, military personnel may also have to deal with morally injurious events, examples of which include witnessing the aftermath of violence, coming to grips with a painful loss, and having one’s moral/ethical beliefs contravened (Nash et al., 2013; Stein et al., 2012). Moral injury has been compared to a primary psychological trauma which may not necessarily be encompassed by a diagnosis of post-traumatic stress disorder (Drescher & Foy, 2008; Shay, 2011).

Following exposure to trauma, military personnel will sometimes look to pastoral care providers for support in an effort to realign their existential beliefs and reaffirm the meaning and purpose of life (Fontana & Rosenheck, 2004, 2005). To this end, pastoral care providers may be in a unique position to illustrate the mental health burden of moral injury.

All Veterans who seek healthcare services through medical centers run by the US Department of Veterans Affairs (VA) have the option of requesting pastoral care services from clinical chaplains. As part of an online survey, VA chaplains were asked ‘What do you see as being the primary emotional component of moral/spiritual injury in Veterans at-risk of suicide?’ (see Kopacz, McCarten, & Pollitt (in press) for a detailed description of this study). Of the 117 chaplains who responded to this question, 58.12% cited despair or hopelessness, 21.37% life having no meaning or purpose, 12.68% guilt, 4.27% anger or resentment and 2.56% sadness or grief (χ²(4) = 149.64, p < .0001).

Although still in its empirical infancy, moral injury represents a war trauma impacting the mental health of military personnel. As research develops in this field, it stands to reason that moral injury may also be found to impact the mental health of civilian and refugee populations. Evidence-based strategies for dealing with moral injury are just starting to develop (Gray et al., 2012). Interestingly, healthcare providers are also becoming ever more mindful of the role religion and spirituality may play in supporting the mental health of their patients (Budd, 1999). Perhaps this is what Carta and colleagues meant by rediscovering the humanistic approach of the Greek, Latin and Islamic medical traditions to improve the lives of those affected by war?