The impact of trauma exposure and moral injury on UK military veterans: a qualitative study

Abstract

Background: Exposure to a potentially morally injurious event (PMIE) has been found to be associated with a range of adverse mental health outcomes. However, how the psychological consequences following PMIEs compare to those encountered after a traumatic, but not a PMIE, remain poorly understood. Objective: The aim was to qualitatively explore UK military veterans' responses to experiences of trauma and moral injury and the impact of such events on psychological wellbeing. Method: Thirty male veterans who reported exposure to traumatic and/or morally injurious events were recruited. Semi-structured qualitative interviews were conducted, and data were analysed using thematic analysis. Results: Six veterans described exposure to a non-morally injurious traumatic event, 15 reported experiencing a PMIE, and 9 described exposure to a 'mixed' event which was simultaneously morally injurious and traumatic. Veterans who encountered a PMIE described experiencing moral dissonance, or a clash between concurrently held sets of values (e.g. military values versus civilian values), which provoked considerable psychological distress. Veterans' cognitions and responses were found to differ following a PMIE compared to a traumatic, but not PMIE, which could have negative implications for daily functioning. Several risk and protective factors for experiencing distress following a PMIE were described. Conclusions: This study provides some of the first evidence that events experienced by UK veterans can simultaneously be morally injurious and traumatic or life-threatening as well as highlighting the process by which moral injury may occur in UK veterans. These findings illustrate the need to examine effective pathways for prevention and intervention for veterans who have experienced a morally injurious event.

Exploring Moral Injury: Theory, Measurement, and Applications

“…However, moral injury is not unique to the US. Dr. Victoria Williamson (King's Center for Military Health Research) presented on work that she and her colleagues have undertaken to examine moral injury within UK veterans (Williamson et al, 2020). Similar to studies of US veterans, Dr. Williamson and her colleagues found that moral injury was a common experience among the veterans they interviewed.…”

The impact of moral injury on the wellbeing of UK military veterans

“…Military service can involve exposure to potentially morally injurious events (PMIEs), which are experiences that violate one’s moral or ethical code [ 1 , 2 ]. PMIEs are understood to generally include acts of commission, omission or betrayal by trusted others [ 3 ].…”

“…PMIEs are understood to generally include acts of commission, omission or betrayal by trusted others [ 3 ]. More recent evidence suggests moral injury can follow ‘ mixed’ events which combine ethically challenging and more routine traumatic events, involving threatened or actual death, serious injury or sexual assault, which are otherwise consistent with criterion A for DSM-5 posttraumatic stress disorder (PTSD) [ 2 , 4 – 6 ]. PMIEs in a military context are not uncommon; for example, 24% of US Marines reported engaging in at least one morally transgressive act and 28% experienced a betrayal event during deployment [ 7 ].…”

Examining the associations among moral injury, difficulties with emotion regulation, and symptoms of PTSD, depression, anxiety, and stress among Canadian military members and Veterans: A preliminary study

“…Preliminary work has begun to examine injury (MI), [3][4][5] defined as the psychological distress asso-potential risk factors for MI in an effort to identify those ciated with committing, failing to prevent, observing, or individuals who are more susceptible to the development learning about an event that violates one's moral and eth-of distress after a morally injurious event. 8,9 Here, qual ical values. 3 MI may result in response to a person's own itative work in a Veteran sample has identified that MI acts of omission or commission (i.e., perceived transgres-could occur after events in which loss of vulnerable per sions) or through witnessing acts of omission or commis-sons occurs.…”

“…3 MI may result in response to a person's own itative work in a Veteran sample has identified that MI acts of omission or commission (i.e., perceived transgres-could occur after events in which loss of vulnerable per sions) or through witnessing acts of omission or commis-sons occurs. 8 Moreover, perceived lack of support from sion by an authoritative individual or group, resulting in leaders, friends, and families, as well as perceived lack of a sense of betrayal. 3,5 Specifically, Litz and colleagues responsibility from leadership, were also indicated as risk have suggested that the ambiguous context of some com-factors for the development of distress after a morally inbat (e.g., difficulty discriminating between enemies and jurious event.…”