At this year’s annual conference of the American Association of Suicidology in Washington, DC, I had the pleasure of listening to a panel discuss the importance of meaning and reasons for living in suicide prevention research and practice. It reminded me of some of the Veterans I currently work with as part of a PTSD clinical team. One of their great challenges is finding meaning and purpose after experiences that have fundamentally changed their view of the world. Many of them have also considered suicide at some point.
The panel’s discussion also reminded me of moral injury, a construct that has been around for some time but has recently received increased empirical attention from those interested in better understanding the experiences of Veterans. Moral injury has been formally defined as “disruption in an individual’s confidence and expectations about one’s own or others’ motivation or capacity to behave in a just and ethical manner” that can stem from “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”1,2 While moral injury shares some characteristics with PTSD (the two are often comorbid), it can also differ in ways that are relevant to suicide prevention. PTSD can develop after a life-threatening experience that elicits intense fear and subsequent symptoms including flashbacks, memory loss, nightmares, insomnia, and hypervigilance.3 Moral injury can develop after a “morally injurious experience” (e.g., killing a civilian during combat or experiencing betrayal by peers or leadership) that elicits intense guilt, shame, or anger and subsequent symptoms including anhedonia, social alienation, loss of trust, and existential conflict (i.e., loss or questioning of meaning).3,4
One argument for developing a more nuanced understanding of stressful military experiences posits that the fear-based model upon which the diagnosis of PTSD was originally built does not adequately account for the variety of events that can be experienced during service (e.g., life-threatening events, traumatic loss, moral injury, and combinations thereof) or variations in the symptoms that can manifest depending on the type(s) of event(s) experienced.5 Another compelling argument stems from evidence suggesting that many Veterans who receive two of the most highly recommended PTSD therapies (i.e., Prolonged Exposure or Cognitive Processing Therapy) still experience clinically significant symptoms after treatment.6
As researchers continue to study moral injury in an effort to better understand its relationship to PTSD, it is worth noting some of the ways in which moral injury is currently measured. One recent addition to this body of literature, the Expressions of Moral Injury Scale, asks respondents about different possible manifestations of moral injury including the extent to which they feel worthy of being loved, withdraw from others, neglect their health and safety, and sabotage efforts to achieve their goals in life.7 Another recently published instrument, the Moral Injury Symptom Scale, is comprised of questions covering various domains including loss of meaning, difficulty forgiving, loss of trust, and self-condemnation.8
So what does this have to do with suicide?
From 2001 to 2014, the rate of suicide among those 18-29 years of age was not only higher for Veterans than for civilians, but also increased substantially among Veterans while remaining stable among civilians.9 Furthermore, PTSD was the most common mental health diagnosis among OEF/OIF/OND Veterans who accessed VA care between 2002 and 2015.10 While PTSD is a risk factor for suicide among Veterans, the mechanisms by which trauma confers suicide risk are not well understood.3,11 Recent studies suggest that moral injury is associated with increased suicide risk, which raises the question of whether some suicidal Veterans referred for PTSD treatment are characterized by a nuanced traumatic profile that includes moral injury.3,12,13 Given the complexity of suicide and the newness of moral injury as an empirical construct, we do not yet know the answer. However, based on current conceptualizations of moral injury and existing theoretical models of suicide, it might be worth looking into.
One of the most popular and extensively studied contemporary theories of suicide is the Interpersonal Theory of Suicide, which posits that both being disconnected from others and believing that one is a burden to others cause the desire for suicide.14 Another relevant theory, the Existential-Constructivist Framework for Understanding Suicide, posits that life’s inherent meaninglessness and isolation motivate the development of constructions (i.e., beliefs and expectations) about the self, others, relationships, and the world which are meaning-based, value-laden, hierarchical, and influence how people interact with their surroundings.15 When fundamental constructions are threatened and ultimately collapse, the result can be adverse cognitive, affective, and behavioral consequences including suicide.
Comparing these theories to current thinking about and measurement of moral injury, one can see overlap. If moral injury is a potential avenue through which we can better understand Veterans who feel disconnected from those around them, guilty, ashamed, or angry about what was seen or done while serving, and adrift in a world that they now view with a different set of beliefs and expectations, then it might also be an avenue through which we can better understand (and ultimately help) some Veterans who consider suicide.
Chris Corona, PhD is a Postdoctoral Fellow at the VISN 2 Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center.
- Drescher, K. D., Foy, D. W., Kelly, C., Leshner, A., Schutz, K., & Litz, B. (2011). An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology, 17, 8.
- Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695-706.
- Bryan, C. J., Bryan, A. O., Roberge, E., Leifker, F. R., & Rozek, D. C. (2017). Moral Injury, Posttraumatic Stress Disorder, and Suicidal Behavior Among National Guard Personnel. Psycholgical Trauma. doi: http://dx.doi.org/10.1037/tra0000290
- Jinkerson, J. D. (2016). Defining and assessing moral injury: A syndrome perspective. Traumatology, 22, 122-130.
- Litz, B. T., Lebowitz, L., Gray, M. J., & Nash, W. P. (2017). Adaptive disclosure: A new treatment for military trauma, loss, and moral injury. New York, NY: Guilford Publications.
- Steenkamp, M. M., Litz, B. T., Hoge, C. W., & Marmar, C. R. (2015). Psychotherapy for military-related PTSD: A review of randomized clinical trials. JAMA, 314, 489-500.
- Currier, J. M., Farnsworth, J. K., Drescher, K. D., McDermott, R. C., Sims, B. M., & Albright, D. L. (2017). Development and evaluation of the Expressions of Moral Injury Scale-Military Version. Clinical Psychology & Psychotherapy. doi: https://doi.org/10.1002/cpp.2170
- Koenig, H. G., Ames, D., Youssef, N. A., Oliver, J. P., Volk, F., Teng, E. J., … Pearce, M. (2018). The Moral Injury Symptom Scale-Military Version. Journal of Religion and Health, 57, 249-265.
- Department of Veterans Affairs (2016). Suicide among veterans and other Americans, 2001-2014. Washington, DC, Office of Suicide Prevention.
- Department of Veterans Affairs (2017). Analysis of VA health care utilization among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn Veterans, from 1st Qtr. FY 2002 through 3rd Qtr. FY 2015. Washington, DC, Office of Patient Care Services.
- Pompili, M., Sher, L., Serafini, G., Forte, A., Innamorati, M., Dominici, G., … Girardi, P. (2013). Posttraumatic stress disorder and suicide risk among veterans: A literature review. Journal of Nervous and Mental Disease, 201, 802-812.
- Wisco, B. E., Marx, B. P., May, C. L., Martini, B., Krystal, J. H., Southwick, S. M., & Pietrzak, R. H. (2017). Moral injury in U.S. combat veterans: Results from the national health and resilience in veterans study. Depression and Anxiety, 34, 340-347.
- Corona, C. D., Wisco, B., Gamble, S., Pietrzak, R., & Van Orden, K. (2018, April). Moral injury, substance abuse, and suicide ideation among Veterans. Poster session presented at the 51st Annual Conference of the American Association of Suicidology, Washington, DC.
- Joiner, T. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press.
- Rogers, J. R. (2001). Theoretical grounding: The “missing link” in suicide research. Journal of Counseling & Development, 79, 16-25.