A topic that received a lot of interest at the CIMVHR Annual Forum was moral injury. This type of psychological trauma is receiving greater interest due to both the increasing incidence in recent deployments and greater attention by researchers and thought leaders, such as Sebastian Junger and Roméo Dallaire.

The U.S. Department of Veterans Affairs defines moral injury as:

“moral injury is a construct that describes extreme and unprecedented life experience including the harmful aftermath of exposure to such events. Events are considered morally injurious if they “transgress deeply held moral beliefs and expectations”. Thus, the key precondition for moral injury is an act of transgression, which shatters moral and ethical expectations that are rooted in religious or spiritual beliefs, or culture-based, organizational, and group-based rules about fairness, the value of life, and so forth.”

The onset of moral injury is linked to the kinds of deployments that Canadian soldiers have been sent on over the last few decades, such as Rwanda, Bosnia, and Afghanistan. These deployments had restrictive rules of engagement and frequent contact with civilian popoulations, in addition to morally reprehensible acts, such as atrocities, genocide. and abuse of women and children.

In “Better Off Dead: Post-Traumatic Stress Disorder and the Canadian Armed Forces,” author, Fred Doucette, gives a long detailed scenario that is capable of inducing moral injury. In the scenario, you are cast as a soldier in Bosnia escorting a convoy of vehicles carrying humanitarian aid. While stopped at a checkpoint, you see the local militia pulling villagers out of their homes and beating them. You want to get out and stop the militia. Your commanders won’t let you, because your job today is to protect the convoy. Some days later, you are sent back to village and investigate, and to count the bodies. The images haunt you, not only of the empty village and mass graves, but also of your initial encounter. The anger and outrage do not receed over time.

Doucette wrote,

Then one day it’s over, you go home and think you have left it all behind. But the guilt, the inhumanity, and the anger, never go away. In your dreams you see their faces. …You start reciting you mantra and tell yourself that you were just following orders, over and over, but that doesn’t work because you are an intelligent, caring Canadian soldier.

The nature of moral injury and its effects are different from other kinds of psychological trauma in important and subtle ways. These are summarized in the Table 1 from a presentation by Albright, Currier, and Hamner at CIMVHR. They key difference is that one’s sense of morality is damaged, rather than one’s fight or flight response. 

Furthermore, the cause of the moral injury could be transgressions by oneself or by others. Moral violations by the chain of command can be especially troubling.

When civilians think of the military and war, do they really consider all aspects of the experience and everything that these individuals must view and rationalize? Moral injuries can stem from direct or indirect participation in combat such as killing or harming others and/or witnessing a death or immoral acts of others. For example, some soldiers will view women and children in harsh and abusive situations and they unfortunately are unable to help. Additionally, during situations in other countries it can be difficult to know who are combatants and who are non-combatants and simply civilians. This can easily blur the lines and allow for innocent victims of war, a triggering experience for many soldiers.

Currently, much of the treatment around PTSD does not focus or put an emphasis on the guilt and shame symptoms that many military feel. Roméo Dallaire mentioned that there was no chapel at neither Royal Military College nor Collège militaire royal. While in battle, many can feel responsible for a death or injury and some of these symptoms and behaviours that can result are:

1. Suicidal and self-harm behaviours
2. Anomie (meaning alienation, purposeless, and social instability)
3. Withdrawn and self-condemning
4. Self-handicapping (by using alcohol or drugs and by damaging relationships)

To support these individuals, resources and moral-ethical training need to be established so the military do not avoid their symptoms, re-experience, or become emotionally numb. There are some cognitive-behavioural therapy techniques currently being used such as the education of inner conflict and moral injury, identifying elements and cognitive attributions related to killing in war, self-forgiveness, and making amends tailored to the individual (i.e., writing letters of forgiveness). Unconditional anonymity with this topic is needed for not only legal implications but to allow those struggling to openly speak about their experiences.