“I knew it was wrong the moment I got the order”: A narrative thematic analysis of moral injury in combat veterans

Abstract

Objective

Moral injury is a nascent construct intended to capture reactions to events that violate deeply held beliefs and moral values. Although a model of moral injury has been proposed, many of the theoretical propositions of this model have yet to be systematically studied.

Method

We conducted semi-structured interviews with eight veterans who reported experiencing morally injurious events during warzone deployments.

Results

Using narrative thematic analysis, five main themes and associated subthemes emerged from the data. The main themes capture the timing of the event, contextual factors that affected the decision-making process during the morally injurious event, reactions to the moral injurious event, search for purpose and meaning, and opening up.

Conclusion

The findings from the present study supported an existing model of moral injury, while extending it in several important ways. Preliminary clinical recommendations and directions for future research are discussed based on the study findings. These include directly exploring the context surrounding the morally injurious event, examining the veterans’ moral appraisals, and helping them assume appropriate responsibility for their actions to reduce excessive self-blame.

Introduction

In war, service members sometimes have to make difficult decisions, some of which may violate their deeply held beliefs and moral values. The term moral injury was coined to refer to the enduring mental health consequences that can occur from participating in, witnessing, or learning about acts that violate one’s moral code (Drescher et al., 2011; Litz et al., 2009; Shay, 1994). Some examples of potentially morally injurious events include disproportionate violence, engaging in atrocities, or violations of rules of engagement (Litz et al., 2009; Stein et al., 2012). Although consensus regarding how best to measure moral injury has not been reached, one preliminary estimate suggested that as many as 25% of a representative sample of veterans endorsed exposure to morally injurious experiences (Wisco et al., 2017). Involvement in these situations has been shown to be associated with a range of negative psychological reactions, including the development of mental health symptoms, such posttraumatic stress disorder (PTSD), depression (Held et al., 2017; Maguen et al., 2010), substance use problems (Wilk et al., 2010) and suicidal ideation (Maguen et al., 2012).

Litz and colleagues (2009) have proposed the sole theoretical model of how moral transgressions result in the development of mental health symptoms. Following the morally injurious event, individuals experience a conflict between the event and their own moral beliefs. For example, a service member may believe that civilians should not be harmed during combat but is involved in an event that involves the death of non-combatants. In an attempt to resolve this cognitive conflict, self-directed attributions of the event’s cause may be made, such as service members believing that they were complicit in non-combatants being harmed. The stable, internal, and global attributions that result lead to the development of painful emotions (e.g. guilt, shame, fear of social rejection) and withdrawal from social interaction. Lack of social contact leads to missed opportunities for potentially corrective information and further strengthens the painful emotions and the stable, internal, and global attributions about the morally injurious event (e.g. Martin et al., 2017). It has been proposed that unless addressed, the moral injury continues to manifest and perpetuate itself through intrusions, avoidance, and numbing in a manner similar to PTSD (Jinkerson, 2016; Farnsworth et al., 2014; Litz et al., 2009; 2016).

Emerging evidence suggests that moral injury-based traumas and danger-based traumas, which primarily involve life threat for self or others, may differ in terms of their impact on mental health. For example, moral injury-based traumatic events have been shown to share stronger associations with guilt, including specific beliefs about wrongdoing, than danger-based traumas (Stein et al., 2012). Furthermore, the relationship between morally injurious experiences (i.e. perpetration by self or others and experiences of betrayal) and PTSD symptoms has been shown to be meditated by guilt, shame, and anger, whereas the association between combat trauma and PTSD symptoms has been shown to be mediated through dissociation and anger (Jordan et al., 2017). Moral injury-based traumas also appear to differ biologically from fear-based traumas. For example, service members who endorsed danger or danger-based traumas demonstrated increased glucose metabolism in the amygdala, whereas those who endorsed non-danger based traumas did not (Ramage et al., 2016).

Although Litz and colleagues’ (2009) model provides a useful framework, and research has begun to examine the circumstances under which morally injurious events occur (Currier, McCormick, & Drescher, 2015), the specific process through which moral transgressions lead to the aforementioned mental health symptoms remains poorly understood (Frankfurt & Frazier 2016). Moreover, little is known about the process through which individuals attempt to resolve their moral injury (Litz et al., 2016). Previous quantitative research has identified that cognitive processes (e.g. the emergence of negative post-trauma cognitions and maladaptive meaning making) play a crucial role in the development of symptoms following a morally injurious experience (Held et al., 2017; Currier et al., 2015). The purpose of the present study was to better understand the veteran’s experience of how negative cognitive and emotional consequences develop following morally injurious events. Given the lack of empirical research in this area, we chose a qualitative approach using narrative thematic analysis to derive common themes which may advance further quantitative research. The identification of common themes could improve assessment of morally injurious experience and have implications for the treatment of mental health problems with moral injury.

Methods

Participants

Participants for this study were recruited from the Road Home Program in Chicago, IL, a specialty mental health clinic for veterans and their families. The study was described to potential participants as an examination of the development of negative emotions following a traumatic experience during deployment. Veterans were able to participate if they 1) were at least 18 years old, 2) male, 3) served in the military, 4) had deployed at least once, 5) had experienced at least one traumatic event on deployment, and 6) had endorsed feeling prominent guilt or shame because of the deployment-related event. Selecting veterans who self-reported guilt or shame related to a specific event was important, as guilt and shame have been identified as hallmark features of moral injury (Jinkerson, 2016; Litz et al., 2009). All of the veterans were either undergoing treatment for PTSD or had completed treatment for PTSD in the clinic. Participants were reimbursed with a $40 gift card for their time. Participant demographics and brief descriptions of their worst morally injurious experiences are displayed in Table 1.

Table 1.

Participant demographic characteristics.

	Participant 1	Participant 2	Participant 3	Participant 4	Participant 5	Participant 6	Participant 7	Participant 8
Age (years)	30	40	48	46	44	51	25	34
Age at Morally Injurious Event	18	37	37	33	Not reported	38	21	20
Current Employment	Employed	Not employed	Not employed	Not employed	Employed	Not employed	Not employed	Employed
Previous Service Type	National Guard	Active Duty	National Guard	Active Duty	Active Duty	Active Duty	Active Duty	Active Duty
Previous Rank Type	Non-Commissioned Officer	Enlisted	Enlisted	Non-Commissioned Officer	Enlisted	Non-Commissioned Officer	Non-Commissioned Officer	Non-Commissioned Officer
Discharge	Honorable	Medical	Medical	Medical	Honorable	Honorable	Honorable	Honorable
Self-Reported Mental Health Diagnoses	PTSD	PTSD, AUD, GAD, MDD, Sleep Disorder NOS	PTSD, AUD, GAD, MDD	PTSD	PTSD, GAD, MDD	PTSD, GAD, MDD	PTSD, ADD	PTSD, Sleep Disorder NOS
Worst Morally Injurious Event	Assaulted elderly civilian	Called in airstrike when children were present	Drove truck over children	Witnessed fellow service members assault women	Watched service member burn in vehicle	Did not intervene when local person tortured and killed	Called in airstrike when civilians and children were present	Used dark humor when dealing with human remains

Procedures

Using narrative thematic analysis (Reissman, 2008), we sought to understand in detail experiences of moral injury, reactions to the morally injurious event and changes in these reactions to the morally injurious event over time. We used Litz and colleagues’ (2009) working model of moral injury as a guide during our analyses, but we did not structure the interview questions or the analysis according to the model. The interviewer, and the members of the analysis team, are primarily oriented towards evidence-based practice, particularly cognitive-behavioral therapy, in their research and clinical work.

All study procedures were approved by the Rush University Medical Center Institutional Review Board and we obtained a Certificate of Confidentiality from the National Institute of Health. Participants provided written informed consent prior to the interview. All interviews were audio recorded and later transcribed verbatim by members of the research team. Any potentially identifying information (e.g., names, specific locations, specific Military Occupational Specialties) was removed during the transcription process. Data files were transferred only on secure systems. No adverse events occurred during the interview process.

Interviews were semistructured, lasting from 43 minutes to 91 minutes. Participants were asked three main questions about (a) their experience of a particular (worst) morally injurious situation, (b) their initial reaction to the morally injurious event, and (c) changes in their reaction to the morally injurious event over time. Follow-up questions were used to clarify contextual information or to ascertain the sequence of events. The first author (PH) conducted all of the interviews. The interviewer had conceptual knowledge of moral injury as well as experience treating veterans with trauma-related mental health symptoms. Participant narratives were accounts of moral transgressions that occurred during deployment in the service of the U.S. military, as well as stories of consequences faced later after returning stateside. Especially relevant for the current study, narratives have been shown to be useful for understanding how individuals make meaning of traumatic experiences in their lives (Hall, 2010; Kirkpatrick, 2008).

Transcriptions were read iteratively by the interdisciplinary analysis team consisting of two men and two women. One woman was a retired service member who is now a nursing professor. Other team members included a nurse researcher, a medical student, and two psychologists. All team members were experienced in mental health care. The team provided means of reflexivity, which has been suggested to decrease disciplinary “blinders” (Bourdieu & Nice, 2004). Analysis began after the first several interviews, so that initial ideas could be compared among individual participants. As more interviews were added, this comparison continued, moving from the related events to their meanings in a dialectical fashion (Josselson, 1995).

After discussing initial themes derived from the first interviews, an organizing template was developed by the analysis team. This included a series of questions or topics which the team had determined would be important foci for analyzing future interviews. This followed the tenets of narrative analysis to be vigilant for certain patterns, or to read for specific content and semantic subtexts. Syntactic or formal analysis of the narratives was minimal, although there were similarities in how the stories were told. The analysis team considered power dynamics (regarding gender, race, group norms, and military rank) embedded in the stories, which added a critical element to our analysis. Individual team members had analytic assignments, which they completed outside of analytic team meetings. The team met a total of four times to discuss and compare interviews, using dialogue, comparing and contrasting, and gradually came to consensus regarding the themes outlined in the findings section. Once their analysis was completed, the analysis team also compared findings with the hypothesized working model of moral injury discussed above (Litz et al., 2009).

In addition to reflexivity, other elements of rigor included assessing coherence, consistency, and verisimilitude of interviews, all of which supported that the accounts were authentic. According to narrative analytic principles (Reissman, 2008), we do not take this authenticity to mean literality, but rather experiential truth. Because of the similarities in these accounts, it is reasonable to expect that the findings have transferability to other deployment-based experiences of morally injurious events and resulting moral injury.

Results

Five main themes emerged from the individual interviews. These themes include: (a) the timing of the moral violations, (b) contextual factors influencing service members’ decision-making, (c) reactions to morally injurious events, (d) the search for purpose and meaning, and (e) opening up and attempting resolution. These themes represent veterans’ reactions to morally injurious situations. Each theme contains several subthemes, which describe specific facets of the respective main themes; however, not all subthemes applied to every veteran in the present study. The themes and subthemes are presented in a chronological manner, starting with the timing of the event and ending with the attempt to make a resolution.

Main Theme 1: Timing

Every veteran in the present study described realizing that their moral values were violated either immediately or very soon after the event. For the majority of the veterans, the negative consequences of the morally injurious event did lie dormant for some time before becoming manifest at a later point.

Subtheme 1: Realization of moral violations occurs in the moment

Veterans described knowing immediately or shortly after the event that their actions went against their own moral code. The realization was described as a sudden insight that what the veteran was doing or witnessing was not morally or ethically right. For example, one participant was ordered to stay in his vehicle, which prevented him from rendering aid to injured soldiers in a burning vehicle: “[I knew that not helping was wrong] the moment I got the order.” Another veteran, who assaulted an elderly Iraqi civilian, noted “It’s crazy because I think I knew in the moment it was wrong…. I know what right and wrong is, and wrong is when you inflict pain or suffering upon someone, and I know that’s wrong.” One exception was a veteran who believed he treated a service member’s remains disrespectfully. The realization that his actions went against his own moral code occurred approximately six months after the event. One possible explanation for the delayed realization was that the veteran attempted to show no emotion to protect other service members. It appears as though the immediate realization that the morally injurious event violated one’s moral code may be prevented through concentrated use of avoidance coping strategies.

Subtheme 2: The cognitive and emotional consequences of moral transgressions can often lie dormant

Another subtheme that emerged is that moral injury can lie dormant for an unspecified amount of time following the initial realization that actions or inactions were wrong. Although most veterans in the present study reported becoming aware of the moral violations immediately, many did not further consider the morally injurious event or develop negative cognitive and emotional consequences until much later. For example, although he knew that he had transgressed his moral boundaries by calling in an airstrike that could possibly harm civilians, a veteran stated that after the event was over: “I never thought of it one time, man, not one time” until he returned home from his deployment.

Veterans described being reminded of the moral violation in a variety of ways. Most veterans described realizing the moral violations after returning home and interacting with civilians. For example, one of the veterans who called in an airstrike that killed civilian children described that seeing his daughters and other children triggered memories of the event:

Civilians are collateral damage to me, but I got a seventeen-year-old, a six-year-old, and a three-year-old. Not that I don’t love my little fucking kids, but just this shit…that image…it fucks with you, you know? Like, I could have did something different.

Another veteran described encountering negative perspectives on the military while in college. Exposure to debates on the ethics of war in his college classes renewed one veteran’s inner conflict over his actions while in Iraq: “They were like ‘killing is wrong. Even the most powerful need responsibility.’ Kind of like calling things out, like, you know, being very hippie about everything. I think that’s when I realized ‘Oh shit!’”

Other reminders, even those that occur during deployment, such as unrelated funerals of fellow service members, can provoke rumination of the morally injurious event. For example, one veteran who drove over children noted that:

I mean, we’re burying these troops, but still in the back of my head, it’s like, “I wonder if they did anything for her? [referring to an Iraqi child that was hit by the convoy]” You know what I mean? But, see, I don’t know how the Iraqis do, you know what I mean? It was like, “poor thing,” you know what I mean? To me, I feel like she would deserve a funeral too or something, you know what I mean?

Several veterans explained that their use of alcohol upon their return from deployment actually facilitated memories of the morally injurious event, though they often intended alcohol to dull these memories. One veteran remarked that he:

Got home, fucking started drinking and shit, and then started seeing images. I ain’t—like the dead bodies and stuff? That ain’t fucking like--I seen shit worse than that, but it’s like I told ya. I can see the fucking motherfuckers right here, right now. I can see the three of ‘em right now.

Another veteran explained:

I was really drunk one night, and it was just like a moment of clarity. It all just kind of flooded back to me and I was a ball of emotions. Thank God nobody was around. That way I could just kind of try and process it myself, you know?

For some veterans, intoxication led to renewed questions about their culpability and served to remind them of their perceived moral transgression. Although we conceptualize alcohol use as a reaction to the moral injury and discuss this under Main Theme 4, Subtheme 4, it appears that it may also facilitate recall of painful memories.

Main Theme 2: Contextual factors influence service member’s decision-making

A main theme that emerged from all interviews was the role that contextual factors play in veterans’ decision-making during the morally injurious events. Specifically, several contextual factors, such as chaos, power and rank, and the perceived need to prove oneself to oneself or the unit impacted the veterans’ decision-making of the situation in the moment.

Subtheme 1: Chaotic situations influence moral appraisals

Several of the veterans in the present study noted that the situations in which the moral injury occurred were chaotic (e.g., urgent radio chatter, taking fire, threat of ambush) and this chaos made it difficult for them to make deliberate decisions about how to act. The constant threat and intensity of the situations in which the veterans were placed required them to make quick decisions. These quick decisions led veterans to scrutinize and question their actions later when they had more time to evaluate other ways in which they could have acted. For example, one veteran who drove over children explained that stopping and checking on the children could have put the entire convoy in danger: “We got to get out of the kill zone. I know it sucks, but its better we keep going, if not, we’re going to be ambushed and stuff.” Weighing staying alive and reducing harm to individuals who are potentially uninvolved with the morally injurious situation can be extremely difficult, especially when the situational pressure limits the ability to weigh all of the possible options properly. In many cases, veterans talked about replaying the situations and thinking about what they could have done differently if the situations had been less chaotic. Veterans stated that this chaos often times made it difficult for them to apply their training:

No matter how much training you do leading up to that, it just never prepares you for when, like, when it actually happens. You just are kind of in a daze about it. Almost like you are seeing it, but you can’t believe it is actually happening.

Another veteran explained that the focus during intense situations is not on the morality of one’s actions but rather on staying alive: “all that matters is that you come home alive.” Importantly, most of the veterans in this study reported focusing on only what they believe they should have done, regardless of contextual factors that may have limited their ability to choose in the situation.

Subtheme 2: Power and rank dynamics can affect moral appraisals

A second subtheme involves the roles that power and rank play in the appraisal process of morally injurious situations. Specifically, by being required to obey orders from higher ranking service members, individuals are sometimes tasked to act in ways they perceive as morally wrong. Cognitive dissonance may be common in these situations because an individual’s moral values would conflict with the values instilled by the military rank structure. For example, one of the veterans who wanted to help fellow service members in a burning truck reported being told “don’t exit the vehicle to help”, despite his intense, immediate desire to render aid to his comrades. Another veteran bluntly stated: “You are a lower enlisted soldier so you have to do as you are told instead of arguing,” even if this involves acting against one’s own moral code.

Veterans who had been in higher ranking position provided a slightly different perspective, which highlighted some of the unique struggles that come with being in charge of other service members. Protecting their fellow service members not only from physical but also from potential legal repercussions was a top priority for these individuals, a priority that may have superseded other values they held. For example, one of the veterans who observed torture of a local person who appeared to have planted an improvised explosive device ordered his subordinates to not record the situation out of concern that his unit would be facing legal problems if the recordings were to surface. It is important to note that the veteran was disgusted by what he had witnessed, but feared that the power structure above him would not prevent positive changes from coming out of this situation.

Veterans who held higher ranking positions also reported struggling with needing to maintain their composure in front of other service members:

Nobody wanted to show sign of weakness so we didn’t talk about things and we just moved on. Once people found out kind of what I was doing [i.e. processing remains], a couple of people had come over and be like ‘hey man, are you okay? What happened?’ Umm I wasn’t ready and so I told them, ‘naw man it’s not as bad as you would of thought it was’ and I kind of protected myself through protecting them. I didn’t want them to think that my mind wasn’t on the mission because you’re a liability if you’re not focused on the mission.

The veteran believed that if others lost confidence in his composure and leadership, this could have negatively affected the mission at hand.

Subtheme 3: Perceived need to prove oneself

During their interviews, several of the veterans remarked that their actions and reactions to the event were in part driven by a perceived need to prove themselves. For example, one of the veterans who assaulted an elderly civilian remarked that other members in his unit had previously done the same and that they likely would have looked at him as not fitting in or being weak for not behaving similarly:

I also did it because I wanted to prove to everyone, like, ‘Look, I’ll beat the shit out of someone, like, it’s okay, like, you know. Someone comes up on us, like I got enough.’ And, I was young, I was an E…, an E2 I think, yeah, just started. So, uh, it was like maybe in my first month or so [on deployment], so I really needed to.

Another veteran explained the culture in his unit was aggressive and violent, while also being tightly knit:

My crew, we were like the badass platoon, and everybody hated us. But, we did a lot of—a lot of stuff that I knew wasn’t right, but at that time though, in the heat of the moment, I didn’t care. And, we all was like a tight-knit-group family, like, it was like, ‘Ay, if you go down, I’m going down with you.’ It was just that tight group right there. No matter what. We’d even go beyond and everything else man, yeah we, we were the shit. We were the shit. I guess.

These veterans spoke about their perceived moral transgressions as a way to demonstrate their ability to fit in with units with aggressive cultures and build trust among others. It is important to note, however, that sometimes this dynamic can cause considerable inner conflict, as in the case of a veteran whose unit was sexually harassing local women. The veteran, knowing this behavior to be wrong, did not participate himself but also held himself responsible for not confronting this behavior more strongly. He stated:

You pay for everything you do, that you do wrong in life. I was wrong in not speaking, you know? I didn’t touch nobody. I didn’t –not even hit nobody. I never abuse…I was a very respectful person.

Main Theme 3: Reactions to moral injury

Another one of the Main Themes that emerged from the interviews covered veterans’ reactions to moral injuries. All of the veterans reported experiencing negative emotional reactions to the morally injurious experiences and many discussed the use of alcohol in an attempt to cope with their feelings. Veterans also explicitly discussed isolating themselves and withdrawing more generally from social interactions.

Subtheme 1: Emotional reactions

All of the veterans in the present sample described developing strong negative emotional reactions following the morally injurious event. While many reported an initial shock or surprise in response to perpetrating or witnessing actions that went against their deeply held beliefs and moral values, all of the veterans discussed feelings of guilt and shame. Feelings of guilt tended to be particularly related to actions during the morally injurious event, such as calling in an airstrike that killed civilians, or not speaking up when members of one’s unit sexually assaulted local women. Feelings of shame were related to the veterans’ overall perception of themselves, some of whom described themselves as “monsters”. For several of the veterans in the sample, the feelings of guilt and shame developed into self-hatred.

Subtheme 2: Rumination

Virtually all of the veterans discussed thinking about the event repeatedly, and the majority described attempting to make sense of why the events occurred in the ways they did and what could have changed the (negative) outcome. Several veterans attempted to explore ways that they could “undo” the event by asking themselves questions, such as “What if I hadn’t looked [at the children]?” or “What if I had never enlisted?” The majority of the veterans explained that thinking through alternatives that could have led to more positive outcomes prevented them from accepting their experiences. Only one of the veterans explained that asking “What if…” had a positive effect, as he had not previously considered whether the children could have not been affected by the airstrike he called in. Rumination about the morally injurious events, such as repeatedly asking oneself “Did [the child] make it? Did [the child] not? Did [the child] get a funeral or proper burial?,” appeared to intensify for many of the veterans once they had returned home from deployment and had more time to think about significant moments of their deployment. In turn, the increased rumination led to intensified negative emotions.

Subtheme 3: Alcohol use

Several veterans reported that they began to use alcohol in attempts to cope with the continuous rumination and resulting emotional reactions. Paradoxically, although the veterans reported intending to use alcohol to reduce the intensity of thoughts and emotions related to their morally injurious experiences, many reported that the use of alcohol led to increased rumination and more intense negative emotional reactions. As one veteran stated:

I came home and started drinking a lot of alcohol. And, it brought back everything from over there. You know, I already had it calloused, it’s like, there’s time I remember about things, but I already tried to – I built a wall, put it on the backburner as much as I could. And right there, it opened up every wound I had.

Subtheme 4: Social withdrawal/isolation

Many of the veterans discussed purposefully withdrawing from their social networks and isolating themselves. Some described the isolation as a way to avoid being reminded of the event, such as by seeing children or other individuals who may resemble those involved in the morally injurious experience. Others described isolating to protect those around them. Specifically, one of the veterans described his morally injurious experience “like an infectious disease,” suggesting that it could ruin the lives of others if they learned what he had done. Relatedly, another veteran described isolating out of fear of what he may – unintentionally – do to others: “If I’m capable of this, what else am I capable of?”

Subtheme 5: Keeping it secret

Through the interviews it became clear that only one of the veterans we interviewed had thoroughly discussed the morally injurious event he experienced outside of treatment. The remaining veterans chose not to share their morally injurious experiences out of fear of what others might think of them if they found out what the veteran had been involved in: “My family doesn’t even know about this incident. I don’t think I told anyone about this.” Several of the veterans explicitly expressed fears of civilians finding out about their actions, as civilians would not be able to understand the veterans’ actions or inactions: “They’d just judge.” One of the veterans who did try to open up to his partner at the time about one of the transgressions he perpetrated shared that he was immediately judged and rejected: “I had one girl tell me I was a baby-killer one time.”

Subtheme 6: Attempts at repair

Although all of the veterans in the present study were still deeply affected by the morally injurious event, many expressed that they engaged in prosocial actions in attempts to “make up” for all of the “morally wrong” things they had done while serving in the military. The prosocial actions veterans described included volunteering, providing for individuals who are homeless, spending significant amounts of money on gifts for their children, and becoming a teacher to help children learn about conflict resolution and the importance of service. It is noteworthy that the prosocial actions usually involved sharing belongings, providing money, or purchasing items as opposed to emotional expressions. One of the veterans described this process as “seeking redemption” and “atonement.” While the specific actions that were intended to assist with the moral repair differed for each veteran, all involved giving instead of taking, supporting instead of destroying, and listening instead of judging. In the words of one of the veterans who became a teacher:

I did my violence. I don’t want anyone else to have to do this. I want to get to a place where we don’t have to do this. What is the complete opposite of violence? Well, being a teacher. What I do as a teacher is the complete opposite of what I did in the military. I’m not teaching kids to kill. I’m teaching kids to share.

Main Theme 4: Search for Purpose and Meaning

The fourth theme that emerged from the interviews is a search for purpose and meaning that veterans appear to engage in following the morally injurious experience. A common meaning that veterans made of the event was that there was no going back to being the old self. Several veterans also equated their actions to those of monsters and subsequently assumed that they became monsters as a result of their actions. Lastly, some veterans expressed difficulties with understanding how their actions or inactions fit with their current roles in civilian life and expressed conflicts with previously held religious and spiritual beliefs.

Subtheme 1: No going back

One of the statements that veterans repeatedly made is that they were now paying for acting in ways that were incongruent with their deeply held beliefs and moral values. Specifically, veterans explained that there was no going back and that “you pay for what you’ve done,” indicating a realization that the morally injurious event cannot be undone. Veterans also expressed a fear that having acted in morally incongruent ways makes it easier for them to continue to act in these ways because they already violated their moral code.

Subtheme 2: Feeling like a monster

A common expression that veterans in the study used to describe themselves was that they had become a “monster.” The identification with the term “monster” was directly related to the veterans’ perceptions of their actions. Specifically, in attempts to comprehend what they had done, many of the veterans described that they could only explain what they did by comparing themselves to a monster or animal: “What kind of animal do you have to be to do something like that?” One of the veterans explained that becoming a monster equates to losing core principles of being human: “If we go down this road we lose our morals, our compassion, our humanity.” Moreover, several veterans expressed a worry that being a monster makes them uncontrollable and potentially dangerous in future situations as well: “… it just makes you think: in a moment of weakness what else could I cast away?”

Subtheme 3: Current role conflict

Throughout all of the interviews it was apparent that the transition from military service to civilian life was difficult for the veterans, in large part because actions that are viewed as normal or acceptable during combat deployments often do not align with actions in the civilian world: “I thought [killing] was my purpose. Now I have no purpose.” Several veterans also acknowledged the conflict of past morally injurious actions with current roles. One of the veterans, who assaulted an elderly civilian explained that what mattered during his deployment used to be staying alive but that this view was inconsistent with his current values, which involved teaching children about the importance of conflict resolution and service: “I’m a school teacher now, and in my past, I beat the shit out of an Iraqi dude. I also teach a kid that’s a refugee from Iraq. The year he was born, I was there.” Another veteran who served on several combat deployments described his role during deployment as follows: “I looked at it [combat, killing] as a job”. As a result, the same veteran also described how much he was suffering because of his actions and how difficult it is now to be a good father to his children.

Subtheme 4: Religious/spiritual struggles

Religious and spiritual struggles played an important role in veterans’ search for meaning and purpose, although it is important to note that only two of the veterans broached religion or spirituality at all during their interviews. The two veterans that discussed religious and spiritual struggles expressed that their actions during the morally injurious events were inconsistent with values instilled in them through their religion or spirituality. Specifically, one of the veterans who relied on dark humor to cope with handling remains of a soldier who died during a mortar attack explained that “in my religion we are all part of God so when we die, we return to God… [My handling of the remains] should have been complete respect.” The veteran also assumed that most other individuals shared his views and therefore “felt alone” and “that people could have any kind of forgiveness in their hearts for me…it scared me and broke my heart because I felt truly alone.” Based on his religious beliefs, he also believed that he was “going to be damned,” which affected his relationships with all other individuals around him as well as God. However, religion and spirituality also played a key role in the healing process for both of these veterans. Talking with a chaplain and being forgiven were described as important milestones that facilitated their recovery.

Main Theme 5: Opening up

The fifth main theme involved opening up to others, including family members, non-professionals (e.g., co-workers), and fellow veterans. Although all of the veterans acknowledged that what they had done was morally wrong and expressed a significant fear of being judged, only some of the veterans actually experienced judgments after they chose to open up. Virtually all of the veterans explained that opening up was difficult but vital in their recovery process, as it provided them with perspectives that they could not have generated on their own.

Subtheme 1: Family members, non-professionals

The fear of being judged and the fear of burdening the other individual with one’s story were the most common reasons for why veterans chose not to disclose the event. One veteran feared that his family could not handle the details of the event: “That’s why I tell you, my wife, I don’t think they could handle it, and then, then they probably could never understand it.” As described above, many veterans tried to keep their experiences secret. However, some of the veterans explained that opening up to family members and non-professionals was crucial to their recovery because it allowed veterans to see their experiences from a different perspective. One of the veterans explained that talking to his wife provided him with a unique perspective on his morally injurious event, which involved having to stay in a vehicle while he watched fellow soldiers burn to death.

I still think we did something wrong… I talked a lot about it with my wife. She gives me different pointers, as far as, you know, the sergeant gave the order, then there was nothing I could do. If the sergeant orders everybody out of the convoy then he’s risking everyone’s lives in the convoy. I took that as a good point. It is a bad thing to say, but it is two lives – you know, if you lose two lives, is that better than maybe losing like 15 other lives?

Subtheme 2: “Nothing like talking to other veterans.”

While many veterans in this study hesitated to open up to family members and non-professionals, opening up to fellow veterans and service members appeared to be easier for some. One of the main reasons why opening up to other veterans was perceived to be easier was because there is an assumed understanding that comes from having experienced the complex exigencies that deployment brings, which results in a sense of mutual trust and perception of non-judgment. Individuals who talked about opening up to other veterans in group therapy settings noted that it was a generally positive and corrective experience: “It was nice to get forgiveness from other people… not everybody thought I was a horrible monster… there is nothing like talking to other veterans.”

Discussion

Through semistructured interviews with veterans who reported having acted in ways that were inconsistent with their deeply held beliefs and moral values on deployment, we were able to identify several common themes. Specifically, veterans discussed the timing of the realization of having transgressed one’s moral beliefs, contextual factors that affected the decision-making process during the morally injurious event, reactions to the moral injury, search for purpose and meaning, and opening up and attempting resolution. For each theme, we identified several subthemes that further captured the veterans’ experiences and that provide a unique perspective on the process that occurs following the experience of a morally injurious event. It is important to note that the identified themes are not experienced linearly. Several of the experiences described in the different main- and sub-themes appear to affect one another. For example, making meaning of one’s actions by identifying as a monster can lead to an increase in negative emotions, including shame. These emotions can further intensify rumination, which often lead to the conclusion that one is a monster.

Our findings providing initial support for the working causal framework for moral injury (Litz et al., 2009). Specifically, our findings support Litz and colleagues’ (2009) postulation that participation in or witnessing transgressions elicits an internal moral conflict, and that veterans who experience moral injury attribute the event to stable, internal, and global factors. Also consistent with other quantitative findings in the moral injury literature, veterans in the present study talked in detail about negative emotional reactions (Farnsworth, Drescher, Nieuwsma, Walser, & Currier, 2014; Jinkerson, 2016; Litz et al., 2009), withdrawal and social isolation (Houtsma, Khazem, Green & Anestis, 2017; Martin et al., 2017), substance use (Wilk et al., 2010) and an inability to forgive themselves (Witvliet, Phipps, Feldman, & Beckham, 2004). As outlined in the model proposed by Litz and colleagues (2009), the internal conflict produced intrusions about the event, which led veterans in the study to use increasing amounts of alcohol (Wilk et al., 2010). Moreover, veterans described that this process decreased opportunities for new learning as well as corrective emotional experiences (Tipps, Raybuck, & Lattal, 2014), and further intensified the negative views of themselves that they had previously generated.

The veterans who participated in the present study also provided important insight into factors that have not yet been considered in conceptual models of moral injury. Virtually all of the veterans described their actions occurring in a particular context, however, the veterans we interviewed did not appear to appropriately weigh these contextual factors in assigning blame for their actions or inactions. Moreover, power dynamics based on the inherent rank structure of the military constrained perception of the available options during the morally injurious events and whether the veterans felt they could speak about the event. It can be speculated that these contextual factors, at least in part, led the veterans to act in ways that conflicted with their moral compass, and that veterans may have acted differently in the absence of these contextual factors. Clinically, it may be important to explore these contextual factors so that veterans can better understand the circumstances under which they acted in morally incongruent ways. Current evidence-based treatments for PTSD, which include both cognitive and exposure-based therapies, assume that greater contextualization of the event helps the veteran to appropriately understand their actions or inactions, which may reduce excessive self-blame (see Held, Klassen, Brennan, & Zalta, 2017; Smith, Duax, & Rauch, 2013; Wachen, Dondanville, & Resick, 2015). When treating veterans who experienced potentially morally injurious events, it is important to explore the morally injurious experiences without judgment in as much detail as possible (cf. Held, Klassen, Brennan, & Zalta, 2017). By successfully integrating the morally injurious experiences with beliefs about themselves, others, and the world, veterans will be able to develop accommodated (balanced) beliefs (Resick, Monson, & Chard, 2016), which can further facilitate the meaning making process.

The veterans in the present study also highlighted the importance of disclosing their experience to others as part of their meaning making process. The veterans specifically referred to the importance of opening up to other veterans, although some remarked that opening up to other veterans was not sufficient. It is possible that exclusively speaking with other veterans about morally injurious experiences may benefit individuals in some ways (experience of non-judgment, understanding), but deprive them of the ability to discuss their experiences with significant others (e.g. spouse, parents, children, faith leaders) who are not veterans. Receiving only the perspective of fellow veterans may limit individuals in their ability to make meaning out of their experiences. Better understanding the meaning making process, including its facilitators and barriers, in veterans who have experienced moral injury appears to be an important direction for future study (Currier, Holland, & Malott, 2015), especially because the experience of a moral injury bears important existential questions (Frankl, 1962).

Another component that is not currently addressed by the theoretical model of moral injury (Litz et al., 2009) is the role timing plays in the generation of cognitive dissonance. Nearly all veterans in this study realized that what they did was wrong in the moment, but the consequences only manifested after a period of reflection and a change in context. This suggests that symptoms associated with moral injury, like symptoms of PTSD (Andrews, Berwin, Philpott, & Stewart, 2007), can lay dormant for quite some time. Thus, even if veterans are not initially distressed by perceived moral transgressions, they may become so in the future.

Lastly, the original hypothesized model (Litz et al., 2009) does not include information about attempts at repair, which was an important aspect the veterans highlighted during their interviews. Although veterans continued to experience mental health problems, engaging in repairing behaviors and attempting to better themselves was mentioned by all of the veterans in this study. We conceptualize these attempts at repair as an important, but not sufficient, step in the recovery process. It appears that engaging in prosocial activities and seeking redemption provided some relief to the veterans but did not fully alleviate the mental health consequences associated with their morally injurious experiences. It is plausible that attempts at repair are part of a more complex meaning making process, which may be particularly important for individuals affected by moral injury (Currier, Holland, & Malott, 2015). Therefore, in addition to helping veterans engage in repairing behaviors, exploring the specific context in which the morally injurious event occurred and examining the veterans’ appraisals of the morally injurious event in the context of a supportive relationship are likely needed in treatment to alleviate symptoms.

There are several limitations that need to be considered. All of the veterans who participated in the study were treatment-seeking. This limits the transferability of the findings, as it is possible that veterans who are not seeking treatment may have different experiences of moral injury than the ones detailed here. Specifically, all of the veterans in the present study were still struggling with the experience of the morally injurious event and it is unclear what resolution of a moral injury may look like. Additionally, veterans who are not treatment seeking may experience their morally injurious event differently than veterans who are seeking treatment. The clinical recommendations derived from this study require further empirical investigation. Specifically, quantitative research comparing treatment responses of veterans with and without moral injury is necessary to determine whether existing evidence-based treatments, some of which focus on and help veterans restructure the appraisals of their traumatic experiences, are also effective for moral injury.

Despite the aforementioned limitations, there was a high degree of consistency among the veterans’ narratives and the present study adds valuable information to the nascent construct of moral injury. Findings from this study highlight the complexity and the various components that comprise the morally injurious experience and its consequences. Further research is needed to determine what distinguishes morally injurious experiences that lead to negative mental health consequences from those that do not. While we suspect that the appraisal of the morally injurious event plays a critical role, this and other mechanisms should be further investigated. Future research should also examine the time course of when symptoms develop following a morally injurious event. Lastly, the role of veteran peer support in repairing moral injury will be another important area to study further, as several of the study participants noted that sharing their experiences with other veterans was an important step.

Clinical Impact Statement.

Our findings suggest that contextual factors, such as situational chaos, power and rank, and the perceived need to prove oneself, may impact veterans’ decision-making process during the morally injurious situation. Therefore, helping veterans to build context in their understanding of a morally injurious event may play a key role in the resolution of the moral injury. Clinicians should also be mindful that veterans who have experienced a morally injurious event frequently report feeling like a monster, social withdrawal, and increased use of alcohol to cope. Encouraging veterans to engage in repairing behaviors (e.g., volunteering) may be helpful.