Exploring Moral Injury and Reintegration Challenges Among Post-9/11 U.S. Veterans: A Qualitative Study

ABSTRACT

Military Veterans face many barriers when reintegrating into civilian society. A growing body of evidence shows that Veterans may experience identity confusion, social isolation, and moral pain during Veteran reintegration. These issues might compound with exposure to traumatic events, leading to the development of moral injury (MI). This study utilizes an exploratory, qualitative approach to look at the relationship between MI and Veteran reintegration to better understand their impact on each other. Twelve Veterans who endorsed experiences of MI completed a cognitive interview utilizing two existing measures of MI. MI and Veteran reintegration appeared to have a dynamic relationship that significantly impacted Veteran’s experiences of moral emotions, their ability to trust others, disclose potentially morally injurious experiences, and make meaning of their service. Mental health practitioners may need to be especially attuned to and assess for MI in reintegrating Veterans, particularly as onset of MI may occur during reintegration as Veterans reflect on their military experiences and come to new moral conclusions. Clinicians and researchers must also foster a significant degree of trust to facilitate disclosure of potentially morally injurious experiences (PMIEs).

What is the public significance of this article?—The results of this study suggest that Veteran reintegration is a significant period of reflection that can impact Veteran’s experiences of moral injury as they come to new moral conclusions about their military service. Providers working with reintegrating Veterans may consider how moral injury can develop over the course of their reintegration.

Introduction

Each year approximately 200,000 service members leave the military and return to civilian society (Parker et al., 2019), a complex process that might include finding employment, continuing education, addressing financial challenges, applying learned skills to civilian life, managing health needs, and resuming and developing a social network (Elnitsky et al., 2017; Sayer et al., 2010; Sokol et al., 2021; Zoli et al., 2015). Reintegration may also be marked by a period of identity development and grief due to perceived loss of purpose, meaning, and camaraderie (Grimell, 2019; Orazem et al., 2017; Verkamp, 2021). Therefore, reintegration can be understood through the ecological factors that influence an individual Veteran’s ability to navigate these tasks (Elnitsky et al., 2017; Sokol et al., 2021).

Many Veterans reintegrate without notable challenges; however, a subset of Veterans face barriers during their transition back into civilian life (Sayer et al., 2014). These barriers might include unemployment, housing insecurity, social isolation, and difficulties with physical and mental health (N. Rattray et al. 2023b; Sayer et al. 2014). According to the PEW Research Center, approximately 44% of post-9/11 Veterans report reintegration difficulties (Morin, 2011). Thus, there is a need to understand specific barriers to reintegration to better support returning service members, Veterans, and their families (Elnitsky & Kilmer, 2017). Moral injury has been identified as a potential barrier to reintegration (Farnsworth et al., 2017).

Moral injury (MI) has been proposed as a condition that arises from the perpetration of, witnessing of, failure to prevent, or learning about events that transgress deeply held moral beliefs and expectations (Litz et al., 2009). Currently, no consensus definition has emerged (Hoyt, 2023; Litz, 2025). However, many proposed psychological definitions share certain themes, including an intense experience of shame and/or guilt that originates from an act that violates the values and ethics that make up one’s moral code, specifically a perceived betrayal by others or by oneself leading to clinically significant impairment in multiple domains (Hollis et al., 2022; Richardson et al., 2020). These events are referred to as potentially morally injurious events (PMIEs) (Litz & Kerig, 2019; Shay, 2014). In one study, approximately 55.4% of post-9/11 Veterans reported exposure to at least one PMIE during their service (Maguen et al., 2020).

From a psychological perspective, MI may develop after exposure to a PMIE with the moral emotions of guilt and shame emerging as the construct’s core features (Farnsworth et al., 2014; Jinkerson, 2016; Litz & Kerig, 2019). MI may include the subjective loss of meaning in life, loss of trust in self, others, and/or humanity, struggles to forgive, a changing sense of self, and observable changes in behavior such as self-harm and social isolation (Boska & Capron, 2021; Farnsworth et al., 2017; Jinkerson, 2016).

Literature on morality provides valuable insights into how MI may interact with Veteran reintegration. To start, morality is an inherently social construct that supports social cohesion and a sense of belonging (Haidt, 2008; Zefferman & Mathew, 2020). Moral systems are comprised of values, practices, institutions, and psychological mechanisms, including moral emotions, that work to manage selfishness and foster social cohesion (Farnsworth et al., 2017; Gilbert, 2019; Haidt, 2008). Moral emotions can be understood as emotions that provide reflexive and intuitive information on one’s moral judgments of specific behaviors, such as anger, guilt, shame, disgust, gratitude, and compassion (Fleming, 2022; Haidt, 2008). Moral emotions are often activated, or intensified, when individuals perceive that others may have judged them to have transgressed morally, which highlights how humans monitor their own morality through the eyes of others (Usoof, 2011). Additionally, these emotions are elicited in response to social issues such as caring, fairness, loyalty, authority, and sanctity (Graham et al., 2009). Therefore, MI can be seen as a response to perceiving a moral transgression and cannot be separated from the person’s social context (Shay, 2003). This is in line with the social-functional theory of MI, which posits that MI can be understood through the social and evolutionary function of morality (Drescher & Farnsworth, 2021). This is notable in the context of Veteran reintegration, as many Veterans struggle to disclose their wartime experiences due to fear of social judgment and alienation. Consequently, Veterans may self-impose a rule of non-disclosure, which can exacerbate experiences of guilt and shame and lead to social alienation, all of which can compound reintegration challenges (Farnsworth et al., 2014; Zoli et al., 2015).

Moreover, some hold that there is no clear, systematic framework of morals within oneself; rather, moral beliefs, actions, and behaviors are a time and place-dependent collection of values that at different times and in different places brush up with other drives and other values (Molendijk et al., 2021). Subsequently, if an individual is removed from a specific time and place a moral value was evoked, they are forced to reevaluate that decision or behavior within a new context (Molendijk et al., 2021). Consequently, there is often “friction” between the many moralities and drives within a person and the different contexts they exist in (Molendijk et al., 2018). This is relevant to MI in the context of Veteran reintegration, as there may be moral dissonance when reflecting on moral decisions made in the context of military culture once back in civilian society (Farnsworth et al., 2014; Moon, 2019). This dissonance can cause confusion within a personal moral narrative (Suitt, 2021), especially as Veterans share their stories with people who might not fully understand the cultural context of the experience (Cronshaw, 2021). The onset of MI may then occur while transitioning back into civilian society and confronting moral emotions due to this dissonance (Farnsworth et al., 2014; Levinstein et al., 2024).

Research question

Veterans face a myriad of barriers that interfere with successful reintegration. MI is a concept that touches on many of these identified barriers, such as social connection and non-disclosure. Therefore, MI might be a particularly salient barrier to Veteran reintegration. While much can be drawn from the existing literature on MI and Veteran reintegration, little qualitative data about MI during reintegration exists. Moreover, as a consensus definition of MI is yet to be reached, exploratory qualitative studies are especially needed. Thus, this study aims to explore the following question: How do MI and Veteran reintegration affect each other?

Methods

Design

This study utilized a qualitative, cognitive interviewing approach using two common measures of MI. The study was approved by the Indiana University Institutional Review Board and VA Research and Development Committee.

Participants and recruitment

This study included a subsample of Veterans who participated in a two-year longitudinal study examining community reintegration among military Veterans with invisible injuries (e.g., depression, PTSD, traumatic brain injury; see N. Rattray et al., 2023b). To facilitate generation of the research questions and subsample, we utilized a theoretical sampling approach, whereby knowledge of existing theories of MI guided analysis of the emerging data to decide what data to collect next and from whom (Draucker et al., 2007). Therefore, from a pool of 75 participants in the parent study, 35 Veterans who endorsed experiences of MI during previous interviews were randomized into three recruitment cycles. Twelve Veterans were consented and completed a qualitative, cognitive interview. Participants were read a statement of informed consent prior to the start of the interview, which included information on confidentiality, privacy, location of data storage, and informing the participant they could refuse to answer any question and withhold details of traumatic events. To manage participant distress, participants were routinely offered a break, and if taken, were given the option to finish the interview on a later date. The team also had a protocol for managing statements of risk made by participants.

Procedure

Qualitative interviews were conducted utilizing a cognitive interviewing approach. This technique facilitates an understanding of how an individual comprehends, judges, and comes to a determination about a specific problem, question, or construct (Willis, 2004). Generally, this method is utilized to validate item content on measures; however, we selected this method to gain an understanding of how Veterans related their reintegration experiences to common questions asked regarding MI. Using this method, participants were given the Moral Injury Questionnaire-Military Version (MIQ-M) and the Expressions of Moral Injury Scale-Military Version (EMIS-M) and asked to think aloud as they answered each question. Participants also completed the Patient Health Questionnaire-9 (PHQ-9) as a practice to acclimate them to the interview method. Following each question on the MIQ-M and EMIS-M, the interviewer utilized planned, proactive probes to facilitate further cognitions specifically relating to reintegration (Priede et al., 2014; Willis, 2004). For example, following question 3 on the EMIS-M (Because of things that I did/saw in the military, I am no longer worthy of being loved), participants were asked “in what ways has this impacted you since separating from the military?” Generally, a sample of 5–15 is sufficient to reach saturation using this technique, in line with qualitative research standards that suggest samples of 8–16 are sufficient to reach 80–90% saturation (Namey et al., 2016, Willis, 2004). All interviews were completed by phone, audio recorded for verbatim transcription, and de-identified prior to coding.

Measures

Expressions of Moral Injury Scale - Military Version (EMIS-M; Currier et al., 2018)

The Expressions of Moral Injury Scale – Military Version is a psychometrically sound 17-item measure of both “self” and “other-directed” MI. Participants respond on a 5-point scale, with higher scores indicating stronger disagreement (1 = strongly agree, 5= strongly disagree). The scale focuses on the cognitive, emotional, and maladaptive behavioral components of MI, such as shame, guilt, moral disgust, beliefs about being unlovable or unforgivable, and self-handicapping behaviors (Koenig et al., 2019).

Moral Injury Questionnaire - Military Version (MIQ-M; Currier et al., 2015)

The Moral Injury Questionnaire – Military Version is a 20-item measure of MI, which focuses on morally injurious experiences during active duty. Participants respond on a 4-point scale, with higher scores indicating more frequency (1 = Never, 2= Seldom, 3= Sometimes, 4 = Often). Questions focus on acts of betrayal acts of disproportionate violence inflicted on others, incidents involving death or harm to civilians, violence within military ranks, inability to prevent death or suffering, and ethical dilemmas/moral conflicts (Koenig et al., 2019).

Patient Health Questionnaire (PHQ-9; Kroenke et al., 2001)

The Patient Health Questionnaire-9 is a brief self-report measure for depression. Participants answer on a 4-point Likert type scale with higher scores indicating higher frequency (0 = Not at all; 1 = several days; 2 = more than half the days; 3 = nearly every day). The PHQ-9 is a psychometrically sound measure of depression (Kroenke et al., 2001).

Data analysis

Anchored in thematic analysis (Braun & Clarke, 2022), a team of four analysts completed a series of coding cycles to develop a codebook, code transcripts, and identify themes. The first cycle consisted of “open coding,” which identified key themes for the codes (Miles et al., 2014). A codebook was then created with 19 codes, all of which included a definition and inclusion and exclusion criteria to prevent drift. The four analysts then collaboratively coded one transcript and arrived at consensus to confirm the codebook’s reliability by refining code definitions, clarifying inclusion and exclusion criteria, and collapsing codes as necessary (Goodell et al., 2016). In the second cycle of coding, the codebook was applied to each transcript. Of the 12 transcripts, six were coded by two analysts to prevent drift. For each transcript coded twice, the coders met to re-arrive at consensus and resolve discrepancies by reviewing the codebook to determine the most appropriate code. Based on saliency of key codes, excerpts were extracted and reviewed by the team. During this review, analytic memos were written to capture emergent patterns, themes, concepts, and how the codes relate to the research question (Saldana, 2011). A data matrix was also developed to compare cases. The team then reflected on these findings to align them with existing theoretical frameworks of MI and Veteran reintegration.

Results

Sample characteristics

Descriptive statistics were calculated to characterize the sample (see Table 1). Most of the sample were middle aged (M = 38.92), White (91.67%), male (83.33%) and Army Veterans (75.00%). Table 2 provides participant descriptions, including PMIEs and measure scores.

Table 1.

Descriptive statistics of full sample(n = 12).

	Mean (SD)	Range
Age	38.92 (8.73)	26.0–52.0
Gender
Female	2, 16.67%	–
Male	10, 83.33%	–
Race
Black/AA	1, 8.33%	–
White	11, 91.67%	–
Ethnicity		–
Non-Hispanic	12, 100.00%	–
Military Branch (%)
Army	9, 75.00%	–
Navy	1, 8.33%	–
Airforce	2, 16.67%	–
Combat Veteran	11, 91.67%	–
Deployments	1.50 (1.09)	0.00–3.00
Operations Deployed To
OEF	6, 50.55%	–
OIF	7, 58.33%	–
OND	2, 16.67%	–
Service Length (Years)	13.33 (8.03)	4.00–24.00
PTSD Diagnosis	4, 33.33%
PHQ-9 Total Score	10.08 (6.04)	4.00–25.00
EMIS-M Total Score	41.58 (10.88)	27.00–60.00
MIQ-M Total Score	35.25 (9.25)	25.00–50.00

Operation Enduring Freedom (OEF); Operation Iraqi Freedom (OIF); Operation New Dawn (OND) Post-Traumatic Stress Disorder (PTSD); Patient Health Questionaire-9 (PHQ-9); Expressions of Moral Injury Scale-Military Version (EMIS-M); Moral Injury Questionnaire-Military Version (MIQ-M).

Table 2.

Participant description of full sample (n = 12).

Veteran Pseudonym	Age	Gender	Time since Separation (years)	Length of Service (years)	Deployed	EMIS Score	MIQ Score	Brief Description of PMIEs
Emily	48	F	6	24	Yes	30	27	Immoral decisions of others leading to social isolation; MST
Zach	31	M	5	6	Yes	27	33	Discussed witnessing immoral actions of others
Anthony	42	M	3	20	Yes	54	42	Feelings of betrayal based on experiences with leadership; witnessing sexual assault and preventable deaths
Daniel	34	M	3	9	Yes	37	34	Experiences with partner forces while deployed
Josh	47	M	3	24	Yes	46	38	Feelings of betrayal based on orders given by leadership and discouragement from seeking MH care; experiencing preventable deaths; MST
Kevin	26	M	3	4	No	52	25	Feelings of betrayal based in reason for discharge and discouragement from seeking MH care
Jerry	36	M	3	9	Yes	30	25	Seeing living conditions in other countries and interactions with children; Feelings of betrayal for how his family was treated during his service
Kate	49	F	4	23	No	45	43	Feelings of betrayal relating to mission; MST
Andrew	37	M	7	7	Yes	49	50	Feelings of guilt and shame related to deaths of fellow service members (suicides) and civilian children; MST; how he treated civilians
Michael	52	M	8	19	Yes	60	50	Feelings of betrayal based in reason for discharge; feelings of guilt for combat experiences
David	27	M	6	4	No	32	29	Difficulty trusting due to experiences with leadership and mission
Justin	38	M	4	11	Yes	37	27	Feelings of betrayal due to number of suicides in the military; witnessing attempted suicides and domestic violence as military police

Potentially Morally Injurious Experience (PMIE); Moral Injury (MI); Military Sexual Trauma (MST); Mental Health (MH).

Qualitative themes relevant to Veteran reintegration and Moral Injury

Four primary themes were identified reflecting elements of MI in Veteran reintegration: Moral Injury’s Role in a Changing Sense of Self and Belonging During Reintegration, Trust’s Impact on Social Connection and Disclosure During Reintegration, Confronting Moral Injury in Reintegration and Reflecting on the Cost of War, and Moral Injury’s Impact on Post-Traumatic Growth. Anonymous excerpts are provided to illustrate themes; all names used are pseudonyms.

Moral Injury’s role in a changing sense of self and belonging during reintegration

Participants highlighted how the persistence of moral emotions associated with MI, specifically shame, guilt, and anger, changed their sense of self and affected their ability to experience a sense of belonging during reintegration. Michael captured how his guilt stems from his experience distributing aid in Iraq. He stated that churches would send toys to his base for troops to distribute to Iraqi children while on patrols. After doing so, his leadership informed him they could no longer provide this aid as they learned insurgents would follow children home after receiving toys from American soldiers and kill their family. In the following excerpt, “Michael” describes the persistent guilt he experiences daily when reflecting on this experience:

I mean, you gotta live with that [guilt] cause you give a small girl a Barbie doll, it costed her and her whole family their lives … It brings a tear to my eye, you know? How many children did I have killed over there because I gave them a stuffed animal or I gave them some food, you know? You get a little pissed off every day, so life for me every day sometimes is hard, it really is. (Michael)

Michael described how this guilt drove him to “lash out” at his wife and kids upon returning home, ultimately leading to strained, distant relationships. When reflecting on how this changed his perception of himself, Michael stated: “that’s what the Army done to me. It’s made me a mean, ugly, terrible person on the inside and I try to keep it on the inside but sometimes that ugliness comes out.” Consequently, Michael put distance between himself, his family, and his peers, ultimately leading to a sense that he did not belong in his civilian community.

Veterans echoed how their persistent moral emotions stemming from PMIEs changed their sense of self. “Andrew” discussed the continued shame he experiences after realizing his capacity to kill, which he learned following a specific moment of rage in Afghanistan:

We went to secure a compound one night, and we got shot at, and we captured the guys that shot at us, and I did the same thing. Like we had them down on the ground, on their knees, hands tied behind their back, and I stuck the muzzle of my rifle in their face, and I was screaming at them. I have never been that angry in my life. It’s like I wasn’t even human anymore … when people say they don’t understand how people could do horrible things, I understand how, because in that moment I would have killed them if I was allowed to … It’s something that I wish I could undo that I can’t, and that shame is there that kind of drives me insane. (Andrew)

For Andrew, this experience fundamentally violated his moral understanding of himself, which impacted his sense of belonging upon reintegrating into civilian life. When describing this he compared himself to the character of Charles Marlow in The Heart of Darkness by Joseph Conrad (1899), “I felt a pretty strong connection to [him] because it’s like he goes through all that crazy shit, going down the river to find Kurtz, and then he goes back to civilization, and it’s like he doesn’t feel like he quite fits in. I guess that’s how I feel.” He goes on to describe himself as a “a bitter, miserable person,” and detail how his persistent shame, changed sense of self, and lack of belonging “ended up costing me my marriage and my house and everything.”

Where Michael saw himself as mean and ugly and Andrew as bitter and miserable, five other Veterans described how experiences of MI changed their sense of self, and they now view themselves as “a failure,” “jaded,” “begrudging,” “not good enough,” and “angry.” “Kate” stated that due to military sexual trauma and betrayal by leadership, she has “become more discerning, more judgmental, more jaded about the capabilities of humans…that’s been really hard. And I still struggle with it.” When describing how this shift has impacted her reintegration, she stated: “I stay away to some extent, stay away from intimacy, even though I think we all seek intimacy. We want to be loved. But I’m like, no, you’re going to turn on me, just like they all do.”

Trust’s impact on social connection and disclosure during reintegration

Veterans illustrated the difficulty of trusting others due to how MI impacted their ability to connect to different aspects of their social network and disclose their military experiences during reintegration. For some Veterans, their lack of trust was with specific groups of people, such as men or civilians. For others, their lack of trust was exhibited by a hypervigilance to others’ motives or a general lack of trust in the world. Yet across interviews, Veterans discussed deliberately isolating themselves following the trust they lost in others during their service due to moral violations. “David” described how his experience of being forced by his leadership to hide incidents of corruption and sexual abuse impacted his ability to trust others upon reintegrating.

I just wasn’t ready to trust the world yet, so there were times where I passed on opportunities to be happy, and to make those friends and have those experiences, which could have lent me the confidence to go out and really swing for the fences in my college. (David)

David highlighted how this lack of trust led to significant social isolation in college, which he attended after separating from the military.

Notably, Veterans also discussed struggling to share their military experiences with civilian peers due to their lack of trust in civilians’ capabilities to understand their military experiences without judgment. This lack of trust and decision not to share further led Veterans to withdraw from civilian peers. “Daniel” discussed worrying his civilian peers may judge him if they learned of his involvement in collateral civilian causalities during his deployment to Iraq:

I don’t share about a lot of the things that happened to me or things that I did. Maybe I worry that someone would pass judgement on me, or people wouldn’t understand, or they just want a cool story, they wouldn’t appreciate how terrible those things could be for the people who experienced them … [or] people whose opinion I care about, or we share a value system, you know would judge me and maybe I don’t build as many relationships because they don’t understand that they don’t have the grace to know I am drowning. (Daniel)

Daniel emphasized that this lack of trust led to significant isolation during his reintegration, which in turn reinforced both his shame and his fear of disclosing his experiences with others.

Finally, Veterans discussed the difficulty associated with building enough trust with their mental health care providers to disclose PMIEs. “Josh” expressed how two years into treatment, he had not disclosed certain PMIEs to his provider due to a difficulty with building trust:

I don’t even tell my therapist everything. I don’t even tell her. I trust her. And she knew that I had trust issues. And it’s been two years. I’m a lot more open with her, but there’s still things that I still have reservations with certain things that I just can’t let go. (Josh)

Josh further explained that his inability to fully disclose his experiences in therapy has left him in “a lonely place” during his reintegration, something he stated he continues to navigate.

Confronting Moral Injury in reintegration and reflecting on the cost of war

Reintegration appeared to be a distinct period in which Veterans reflected on their military experiences and came to new moral conclusions about what they had done or seen. David captured this sentiment when he stated:

When reintegrating and talking to people and getting new perspectives and seeing what’s normal in the civilian [world], I was able to look back at who I was while I was in the military with new lens and realize maybe that’s not who I want to be and that eventually became, no, I don’t want to be going down that path, I can’t believe I ever went down that path. (David)

This was echoed by many of the Veterans who discussed reflection of their values being initiated by their new, civilian cultural context. This in turn made them reevaluate experiences they had, or the values held while in the military through a new cultural lens.

Veterans also attempted to make sense of their PMIEs during reintegration, leading them to grapple with moral questions about war. Many Veterans discussed asking themselves a vexing question: “was it worth it?” This was evident in Veterans reflections on the deaths of fellow service members. Daniel expressed how his grief was impacted by his experience of betrayal surrounding the loss of his friends and desire for civilians to grapple with the cost of war:

For me, a lot of friends and you know other guys who didn’t come home, and it’s like no one is going to say, OK, what is an actual cost that’s worth it, what was this really for … I just, like my friend just died and my life is forever changed and no one took the time to like figure out, hey, was it worth it, … they are so far removed from like the human cost of the war … I just, it really hurts cause it just makes me feel like they don’t care about you, and you feel less valued. Maybe that is why I keep my circle tight because people that are in my circle value me. (Daniel)

This sentiment can be seen again in Andrew’s grappling of the death toll of the war in Iraq:

All that could have been avoided. All those dead people could still potentially be alive now if it wasn’t for us invading Iraq. At the time, I was all about it. I was like, yeah, I’m going to go to Iraq, this is great, I love war. But that was pretty stupid. (Interviewer) So this is something that’s come since separating? (Andrew) Yeah, just looking back, it’s like, what the hell did we even go there for? You could say I’m pretty disillusioned about the whole thing (Andrew)

Veterans also captured how experiences of MI developed during their reintegration. For some Veterans, developments in the conflict they served in continued to impact them during reintegration, which led to experiences of MI. Veterans illustrated that watching events unfold from a civilian context led to experiences of betrayal. “Anthony” highlighted this stating:

Do I have moral injury with my government about Afghanistan? Sure. I watched our soldiers and sailors and Marines loaded on planes and taken home, those flags on the body bags. And we just let [the Taliban] have it back … So, yeah. A lot of people died for no reason. And honestly, [the withdrawal is] a huge betrayal. That’s like, that’s kinda how I feel. I feel like our government betrayed me. (Anthony)

Other Veterans discussed how they were hyper-attuned to the ongoing activities of their former units, particularly deployments, casualties and injuries, and leadership developments. Consequently, moral emotions that were not present at the time of separation developed during their reintegration, causing significant impacts. David discussed the guilt he felt after learning about a fellow service member’s death following his unit’s deployment soon after his separation:

My unit deployed right after I got out, for me to deploy I would have had to sign on for another 3 years and I just wasn’t willing to give that much of my life to the military. When they deployed, a sister infantry battalion within the brigade had one death. When I found out about that death, I started feeling extremely guilty for not going on deployment. That messed with me for a very long time. (David)

Moral Injury’s impact on post-traumatic growth

Several protective factors emerged from Veteran’s narratives regarding processing PMIES during their reintegration. To begin, Veterans who demonstrated cognitive flexibility, particularly the ability to accept one’s past actions or take a different perspective, discussed how this seemed to be protective against MI during reintegration. “Justin” described this by stating:

I had to transform my thinking to realize that the past is the past and you are not going to be able to change it, so you have to learn from it, and you have to be able to use that to your advantage. (Justin)

Veterans also discussed viewing their strong reaction to PMIEs as adaptive:

Now looking back at it, it’s like I almost had to go through that, like depression to be where I am at now. It was almost like, it was going to happen, if it, if I wasn’t like saddened or depressed with the stuff I saw, I think there would be something wrong with me, right. So I am like, that was a normal reaction to something like that. (“Zach”)

Other Veterans echoed this sentiment noting that they did not see their psychological response to PMIEs as maladaptive but a normal response to an immoral experience. Some described their strong moral emotions as a “litmus test” to help make different decisions. Overall, the view that their psychological response was adaptive appeared protective in Veteran’s descriptions of MI. Veterans discussed how these strategies led to growth following a PMIE and pushed them to be stronger and resilient versions of themselves. Further, they described how it gave them necessary tools to move forward, which positively impacted their reintegration.

Discussion

Through cognitive interviews with 12 Veterans, the current study explored how MI and Veteran reintegration affect each other. Experiences of MI, such as significant shame, guilt, or an altered sense of self, appeared to impact reintegration by limiting Veterans social capacities, willingness to trust others, and sense of belonging during reintegration. Veterans expressed difficulty disclosing their military experiences to those within their social network, including family, friends, and providers, furthering their social isolation. This can be understood through the social-functional model of MI that holds that moral emotions serve particular social functions (Drescher & Farnsworth, 2021). Specifically, shame has been shown to involve negative appraisals of the self, leading to feelings of worthlessness or fear of exposure (Cronshaw, 2021; Drescher & Farnsworth, 2021). As shown in this sample, Veterans who described persistent experiences of shame also described a changed self-image and infrequent disclosure of their wartime experiences due to fear of judgment by civilian peers. Subsequently, they isolated themselves from their families, friends, and for some their providers. This is in line with other qualitative studies where Veterans have discussed how shame in the context of MI prevented them from disclosing PMIEs to providers (Meis et al., 2023). Overall, this social isolation is significant as it is a known barrier to reintegration and a significant component of MI (Boska & Capron, 2021, Bloeser et al., 2014; N. A. Rattray et al., 2023a; Sayer et al., 2021). Results of this study indicate that social isolation during reintegration may be a specific function of MI in this context as elements of MI (e.g., shame and trust) led to isolation and non-disclosure, which in turn impacted Veterans reintegration experiences.

Veterans also illustrated how reflecting on their military experiences throughout reintegration, often prompted by civilian culture or developments in the ongoing conflicts, led them to form new moral conclusions about their experiences. Some asked whether their service was “worth it,” initiating a reevaluation of military experiences, identities they held, or things done to them, which in turn led to or increased experiences of MI. Veterans’ descriptions of reflecting on and reevaluating moral experiences during reintegration echoes other studies that show evaluations of moral experiences to change when examining the experience within a new cultural context (Molendijk et al., 2021). This tension between military and civilian identities has been described as the “civilian-to-military-divide” or “warring identities” (Cronshaw, 2021; Sachdev & Dixit, 2024; Smith & True, 2014) and highlights how this reintegration experience may impact MI. Additionally, some Veterans drew new conclusions about their military experiences well into reintegration leading to new experiences of MI, which supports the finding that MI may have a delayed onset following reflection on PMIEs in a new moral and cultural context (Cahill et al., 2023; Farnsworth et al., 2014). The results of this study add to this understanding by positing reintegration as a critical period in which this reevaluation occurs.

Protective factors were also identified in the relationship between reintegration and MI. Veterans demonstrated that their ability to maintain cognitive flexibility by accepting past actions and holding multiple perspectives simultaneously helped them move forward in their reintegration and work through potential MI. Veterans also discussed how they grew from PMIEs and subsequently had greater success in their reintegration. These narratives are consistent with descriptions of posttraumatic growth, which can be conceptualized as positive psychological change or transformation that occurs instead of or alongside trauma symptomatology, and MI (Evans et al., 2018). Veterans illustrated that this growth led to connection with others and a greater sense of purpose during reintegration. Furthermore, it has been shown that psychological resilience plays a substantial role in Veteran well-being (Vogt et al., 2021). It is then consistent that Veterans who demonstrated resilience to MI through cognitive flexibility had better reintegration experiences. This is also significant in the context of the high prevalence rates of PMIEs (Maguen et al., 2020). Specifically, given the high potential for exposure to a PMIE, these narratives emphasize how Veterans may respond to these exposures with resiliency.

Strengths and limitations

One strength of this study is its longitudinal design, which may have fostered trust and disclosure. Disclosure of PMIEs by Veterans for research may be limited. However, the Veterans in this study were highly disclosing and rarely declined to comment further. The only question Veterans consistently chose not to share details about was question 13 on the MIQ-M, “I was sexually assaulted.” One explanation for the level of disclosure granted for this study may be its longitudinal design. This was the sixth interview these Veterans completed over a minimum of two years, during which most were interviewed by multiple team members. Therefore, while the first author had not previously interviewed these Veterans, a level of trust was granted due to the trust they had in the team that was built over time. Many participants stated this explicitly and noted that their understanding of the study’s purpose increased their desire and willingness to participate. Therefore, the longitudinal design may have important implications for qualitative research on MI, namely, that building trust over time may be critical to eliciting rich data.

A significant limitation of this study is the sample’s limited diversity, particularly its gender and race composition. This also highlights the limitations of utilizing a convenience-based sample, as the parent study’s sample was more diverse. Consequently, our study is intended to offer exploratory descriptions rather than generalizable findings. Finally, a significant limitation of this study is reflective of a limitation of the current state of the MI literature. As there is no consensus definition of the MI construct, nor are there agreed upon cut scores for the measures used, it is difficult to determine who has clinically significant levels of MI in this sample (Hoyt, 2023; Litz, 2025). Given this dilemma, we felt it was important to show each participant’s score (see Table 2); however, we cannot rule out the possibility that these scores could be related to other psychopathology with overlapping symptoms (e.g., PTSD). As such, another limitation of this study is the absence of measures for anxiety, PTSD, or personality measures. Further triangulation of the data with an expert panel would strengthen our findings. However, what follows from these limitations is a need for more discovery oriented, descriptive qualitative studies on the construct of MI. Therefore, the exploratory nature of this study and its identification of future avenues of empirical research is an overall strength.

Clinical implications

Two distinct clinical implications emerged from this study. First, as Veterans’ willingness to disclose PMIEs was significantly limited, providers may need to explicitly ask Veterans about experiences of MI, which can be aided through existing questionnaires. Secondly, as reintegration may be a distinct period of reflection and reevaluation of PMIEs leading to the development of MI, it may be beneficial to routinely assess for MI in reintegrating Veterans. Additionally, if the conflict in which a Veteran served continues following their separation, providers should discuss these developments with Veterans, as this may also provide the basis for new moral reflection and conclusions of past experiences.

Conclusion

This discovery oriented, qualitative study sought to better understand the relationship between MI and Veteran reintegration. Veterans illustrated how MI impacted their sense of self and belonging during reintegration. MI also appeared to lead to increased isolation, as Veterans discussed difficulties trusting others, forming social connections, and disclosing PMIEs. Moreover, the interplay between civilian and military cultures is central in the reflection and reevaluation of military experiences that occurs during reintegration. Therefore, reintegration may be a time where Veterans draw new conclusions about past actions and develop MI. However, MI may not always be a barrier to Veteran reintegration and in some cases can strengthen a Veteran’s cognitive flexibility, moral identity and purpose in their reintegration.

This study highlights several areas that would be beneficial for future exploration. Firstly, reintegration as a critical period in which MI may develop should be empirically investigated. Empirical studies on specific clinical interventions that reduce shame, foster trust, and facilitate disclosure of PMIEs should also be investigated. Future research might also focus on how MI during reintegration varies across subgroups within the Veteran population (e.g., service branch, combat vs non-combat). Finally, VA should continue to reevaluate its operational definition of MI and assess how this may impact clinical care as research into the construct continues to evolve.

Funding Statement

This research was supported by Career Development Award (NAR) from VA Rehabilitation Research and Development (D2642-W).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

These data must remain on Department of Veterans Affairs servers; investigators interested in working with these data are encouraged to contact the corresponding author.

Authors’ contributions

LD is primary author, primary investigator, and contributed to a significant portion of the manuscript. KS is secondary author due to their significant contribution to the study and present manuscript. AND served as project manager throughout the study and reviewed the manuscript to provide feedback. NT and MS served as dissertation committee members for LD and provided their expertise, input, and feedback throughout the study development and manuscript process. NR served as senior author, mentor, and reviewer throughout the study and manuscript process. NR is also the primary investigator for the parent study this investigation was a part of. All authors read and approved the final manuscript.

Ethical approval

Ethics approval consent to participate: This study involves human participants. This was approved by the Indiana University Institutional Review Board (approval #1806083802) and Roudebush Research and Development Committee. All methods were carried out in accordance with Indiana University Institutional Review Board and the Veteran’s Administration Roudebush Research guidelines and regulations for human research. All participants gave consent for participation in this study. Participants gave informed consent to participate in the study before taking part.