Moral injury in post-9/11 combat-experienced military veterans: A qualitative thematic analysis.

Abstract

War zone exposure is associated with enduring negative mental health effects and poorer responses to treatment, in part because this type of trauma can entail crises of conscience or moral injury. Although a great deal of attention has been paid to posttraumatic stress disorder and fear-based physiological aspects of trauma and suffering, comparatively less attention has been given to the morally injurious dimension of trauma. Robust themes of moral injury were identified in interviews with 26 post-9/11 military veterans. Thematic analysis identified 12 themes that were subsumed under four categories reflecting changes, shifts, or ruptures in worldview, meaning making, identity, and relationships. Moral injury is a unique and challenging clinical construct with impacts on the individual as well as at every level of the social ecological system. Recommendations are offered for addressing moral injury in a military population; implications for community public health are noted. Impact StatementMilitary veterans who experienced moral injury-events that violate deeply held moral convictions or beliefs-reported fundamental changes following the morally injurious event (MIE). The MIE ruptured their worldview, or sense of right and wrong, and they struggled to reconcile a prior belief system or identity with their existence post-MIE. Absent a specific evidence-based intervention, clinicians are encouraged to consider adaptations to existing treatment models but to be aware that moral injury often does not respond to treatment as usual for PTSD or adjacent comorbid conditions.