PAPER – Moral Injury and Suicide Among US Veterans

Assignment – Scholarly Paper – Multicultural Perspectives on Death and Loss: Students will write a scholarly paper on a cultural, religious, and/or spiritual perspective on death that has not been part of their own personal history and a topic of personal interest. The paper should include a title page (no abstract required) and should be 1015 pages in length (not including title page and references). The paper must be written in APA Style (7th Edition).

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Moral Injury and Suicide Among US Veterans

After analyzing 55 million medical records from 1979 to 2014, the United States Department of Veterans Affairs (VA) published a report in 2016 indicating that an average of twenty veterans commit suicide daily (Office of Suicide Prevention, 2016). Based on drug overdose deaths and other overlooked causes of death associated with suicide and self-injurious behavior, a 2022 study determined that up to 44 veterans commit suicide daily (Shane, 2022). According to these statistics, the veteran suicide rate is extremely high, roughly double that of civilian professions (Ramchand, 2022). To better understand this subject, this paper examines moral injury and its relationship to suicide among US veterans from a cultural, religious, and spiritual perspective.

Understanding the Complexity of Moral Injury

This section presents a foundational understanding of moral injury, including moral agency and three subscales of moral injury. To comprehend the complexities of moral injury and its effects on an individual, a case study is also utilized. This case study will also represent numerous other US veterans, particularly those with a similar cultural, religious, or spiritual orientation.

A Case Study of Moral Injury

A few years ago, I worked therapeutically with a former Marine whose name is Jeff, a fictitious name. Jeff enlisted in the Marine Corps at a young age after being born in the mid-1980s to a traditional American working-class family. He grew up in a Christian Lutheran family with a fairly nuanced and tolerant religious outlook. Over time, he also developed a spiritual perspective on the world and himself. Jeff’s cultural, religious, and spiritual orientation will be discussed further later.

Initially, Jeff sought assistance for post-traumatic stress syndrome (PTSD) because he exhibited classic PTSD symptoms in accordance with DSM-5 (2013), including having been in several situations where he was injured and in danger of dying (PTSD criterion A: stressor), having intrusive memories of these situations (criterion B: intrusion symptom), having a deteriorating mood, and being easily triggered in situations where he felt threatened (criterion B: intrusion symptom, and Criterion E: alterations in arousal and reactivity), avoidance of places that caused him to lose his temper (criterion C: avoidance), engaging in self-destructive and risky behavior (criterion E: alterations in arousal and reactivity), had difficulty experiencing positive affect and as a result self-medicated to avoid negative affect and thinking about what he had been through (criterion D: negative alterations in cognitions and mood), and all of these symptoms had been present for at least one month (Criterion F: duration). Although Jeff initially responded positively to traditional PTSD treatment, which included stabilizing his nervous system and gradually exposing and integrating some of the traumatic events he had experienced, the positive effects were only temporary. When Jeff began sleeping and feeling better, and simultaneously began to organize his life, by starting a new job or project, he frequently ruined things for himself, for instance, by getting into fights, abusing drugs, and often eventually ending up contemplating suicide.

As Jeff’s PTSD symptoms, which were primarily a result of his exposure to life-threatening situations during his two tours in Iraq, subsided, feelings of guilt and shame emerged. After multiple sessions with Jeff and a discussion with his former therapist, it became evident that Jeff had committed violent acts for which he could not forgive himself. He felt anger towards himself for what he had done, as well as anger towards the United States government and various representatives for making him fight in a war he felt was unjustified. Since Jeff was a raised Christian, he placed a high value on doing the right thing, being truthful, and displaying care and compassion for others, all of which he felt he had failed and continued to fail to do. Due to the intense guilt, shame, and anguish he felt for his transgressions, Jeff believed he was a bad or even evil person who deserved nothing good in life. As a result, whenever he started to feel better, he self-sabotaged his life, recklessly used drugs, and got into fights, as if he felt he did not deserve to live any longer.

The Concept of Moral Agency

In accordance with Litz et al. (2009), Jeff’s intense negative emotions, such as guilt, shame, and anguish, indicate that he has an intact moral belief system. These emotions indicate that his conscience is functional, that is, that he possesses the cognitive and emotional capacities necessary to act morally and comprehend the moral repercussions of his actions (Litz et al., 2009). This ability to act morally is referred to as moral agency and means that an individual or group can make and act on decisions that are consistent with their ethical, cultural and religious/spiritual values (Milliken, 2018). Thus, moral agency is the capacity to make moral decisions consistent with one’s conception of right and wrong and to accept responsibility for the consequences of those choices. When a person assumes moral responsibility for an event where they believe they have failed to live up to their moral compass, regardless of who performed the action or who bears the responsibility, moral injury may occur (Currier et al., 2018; Litz and Kerig, 2019). Jeff’s feelings of regret and self-blame are directly related to his moral agency, as he believes he could have made a different decision or taken a different course of action but did not, leaving him to wonder if he is a bad person at heart. Thus, failure to maintain moral agency results in intense feelings of not only self-betrayal, guilt, and shame (Dombo et al., 2013), but also regret and self-blame, which are crucial components to address in the actual therapeutic process.

Transgressive Acts and Three Subscales of Moral Injury

During war, soldiers face a variety of moral and ethical dilemmas that may conflict with their values and fundamental moral beliefs, putting their moral agency to the test. Moral injury may occur when a soldier commits an act that violates their moral compass, such as killing civilians or failing to prevent others from committing atrocities. This act is typically transgressive in its nature, which means that it frequently exceeds acceptable moral, social, or legal limits or boundaries. More specifically, Litz et al. (2009) define transgressive acts as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply help moral beliefs and expectations” (p. 700). In addition, Drescher et al. (2011) emphasize that it is the inhumane and cruel nature of these acts, such as causing pain, suffering, or even death, that renders them morally reprehensible and therefore unacceptable to oneself and others.

It is not only the aspect of committing a transgressive act oneself that can cause moral distress and associated feeling, but also preventing someone else from committing these actions. No matter if it concerns preventing oneself or someone else from committing an action one perceives as morally wrong, the associated guilt, regret, and self-blame may be equally strong. Moreover, when an organization one is affiliated with, or its leadership, engages in transgressive acts directed towards oneself or others, feelings of betrayal may arise, which can also result in moral injury. Thus, moral injury can be divided into three categories based on the perpetrator of the offense; Transgressions-Self, Transgressions-Other, and Betrayal. While the first category, Transgressions-Self, refers to when a person themselves commits a moral transgression, the second category, Transgressions-Other, refers to when a person witnesses someone else committing a moral transgression (Litz et al., 2009). The third category, Betrayal, refers to when a person feels angry and betrayed by coworkers, superiors, an organization, or society as a whole (Molendijk, 2018).

In Jeff’s case, he falls under the first category, Transgressions-Self, as he committed the transgressions himself. Regarding the second category, Transgressions-Others, I am reminded of a client who witnessed others conducting excessively brutal enhanced interrogation on a prisoner. Intriguingly, this client, who may be referred to by the fictitious name Jennifer, repeatedly attempted to suppress her deeper feelings of guilt, anger, and anguish to the point where she had difficulty speaking, because her vocalizing muscles were so tense. A group of prison guards at a California maximum security prison during the implementation of the Covid-19 vaccine requirements exemplifies the third category, Betrayal. One of the guards explained that they have plenty of skills and routines to deal with dangerous inmates, but it is difficult to do this type of work when their leadership, including their superiors and federal and state political leaders, do not “have their backs.” One of their colleagues committed suicide one week later. It was believed that the prison guard’s suicide was caused by his feeling of betrayal by his superiors. Over time, a series of events, including poor organizational leadership, understaffing, and a high-stress environment, had accumulated, leading to a buildup of tension, disappointment, and even rage among some of the prison guards toward their leadership.

Suicide Among Veterans due to Moral Injury

As mentioned at the beginning of this paper, the suicide rate among military personnel has more than doubled (Department of Defense, 2011), which continues to confuse not only military leaders, but also mental health professionals who work with combat veterans after they return from war. It has been known for a long time that military personnel and veterans suffering from PTSD are more likely to engage in self-injurious thoughts and behaviors (Bryan et al., 2013; Jakupcak et al, 2009; Leard-Mann et al, 2013, as cited in Bryan et al., 2014). Guilt and shame are prevalent, as are negative changes in attitudes and behaviors related to ethics, morality, and spirituality, as well as difficulties with forgiving and trust issues in interpersonal relationships (Drescher et al., 2011; Vargas et al., as cited in Bryan et al., 2014). Due to the fact that these symptoms have not typically been used as diagnostic criteria for PTSD, researchers and mental health professionals have begun to use the concept of moral injury (Bryan et al. 2014), which will be investigated in greater detail in this section, particularly in relation to suicidal behavior.

The Relationship Between Moral injury and Suicidal Behavior

Bryan et al. (2014) and Nichter et al. (2021) examined the relationship between moral injury and suicidal behavior among US military personnel and US combat veterans, respectively. Both studies found that two subscales of moral injury; transgressions by self and transgressions by others, were significantly associated with increased risk of suicidal ideation and suicide attempts. Notably, these studies also reported that transgressions by self had a stronger association with suicidal ideation and suicide attempts compared to transgressions by others. In addition, Bryan et al. (2014) reported that military personnel with a history of suicide attempts had significantly higher levels of moral injury, both transgressions by self and transgressions by others, than those with a history of suicidal ideation and those with no history of suicidality. Regarding betrayal, the third subscale of moral injury that was not directly examined in the two prior studies, Bryan et al. (2016) discovered that betrayal is significantly associated with an increase in the severity of suicidal ideation among military personnel, although its association with suicide attempts was not explicitly established. This discovery highlights the importance of also considering betrayal as a crucial factor when investigating the relationship between moral injury and suicidal behaviors in military populations. In conclusion, these studies emphasize the significance of considering moral injury, especially Transgressions-Self, as a significant risk factor for suicidal ideation and suicide attempts among military and veteran populations. In addition, Bryan (2011) demonstrates that suicidal individuals are frequently extremely self-critical and have a negative self-image. This self-critical aspect appears to more closely align with the Transgressions-Self group than with the other two subcategories, as transgressions are typically accompanied by heightened self-criticism due to the anxiety, guilt, and shame that result from such actions.

Emotional States Underlying the Three Subscales of Moral Injury

Given that emotions have such a strong influence on thought, action, and behavior (Tyng et al., 2017), it can be beneficial to examine the emotional states underlying the three subscales of moral injury as a means of gaining a deeper understanding of moral injury. It appears that while Transgressions-Self is more associated with feelings of hopelessness, guilt, shame, and pessimism (Bryan et al., 2013), Transgressions-Other is more associated with various forms of emotional distress as experienced in PTSD, most notably hyperarousal and insomnia, indicating that it also contains a fear component (Byrne et al., 2019; Nichter et al., 2020). In the case of Transgressions-Self, shame and guilt are likely associated with one’s own actions that contradict one’s own sense of morality, resulting in feelings of hopelessness and a negative self-image, which can lead to suicidal thoughts and attempts. Transgressions-Other, on the other hand, may involve situations in which others have violated one’s sense of morality or sense of what is right or wrong, which can naturally also lead to feelings of anger, frustration, and even betrayal, all of which can contribute to various symptoms of emotional distress associated with PTSD and insomnia. This is comparable to the betrayal subscale, which appears to be more strongly associated with anger due to the frequent violation of an individual’s trust (Bryan et al., 2014).

The Progression from Suicidal Ideation to Suicide Attempt

As a way to better understand the progression from specific emotional states through suicidal ideation and ultimately to suicide attempts, it is valuable to examine the Three-Step Theory (3ST) of Suicide (Klonsky and May, 2015). This theory is a continuation of Joiner’s (2005) Interpersonal Theory of Suicide, which significantly advanced the understanding of the suicide process, and it has been cited in more than a hundred of scientific papers (Klonsky et al. 2021).

Klonsky and May (2015) describe that suicidal ideation begins with the onset of pain; psychological, emotional, or any other kind of pain that may be experienced. It is hypothesized that this pain is perceived as a punishment for living, decreasing the desire to live, and inciting suicidal thoughts. This hypothesis is based on the idea that behavior is controlled by behavioral conditioning, in which people perform more of the behaviors they are rewarded for and less of the ones they are punished for. However, if a person has hope that their life will improve, that hope can provide the motivation to alter their life circumstances, thereby reducing their pain and preventing suicidal thoughts. Consequently, suicidal ideation requires both hopelessness and pain to be present in a person life, which together makes out the first step of the 3ST of suicide.

According to the 3ST, the second step toward potential suicide is connectedness, which includes relationships with both other people and any other object or activity that gives life meaning and interest, such as a rewarding friendship or meaningful hobby. As long as the subjectively experienced connectedness, which provides meaning to one’s life, is greater than the subjectively experienced pain, connectedness provides protection against suicidal ideation. Although Jeff frequently felt hopelessness and pain in his life, he was very likable and often reached out to others when he was at his lowest, thereby increasing his sense of connectedness and decreasing his suicidal ideation from strong to moderate. In the case of the prison guard who committed suicide, however, he isolated himself, and as a result, the protection afforded by connectedness was eliminated. In addition, he frequently abused alcohol and suffered from mild depression, two factors that may increase the likelihood of suicide (Ringer et al., 2018).

The third and final step in 3ST relates to three specific variables that contribute to an individual’s capacity to commit suicide, namely dispositional, acquired, and practical factors. Dispositional factors are characteristics that are typically determined by genetic factors, such as a person’s sensitivity to pain (Young et al., 2012) or fear of blood (Czajkowski et al., 2011). This means that a person who is not afraid of pain or blood may not be deterred by a suicide attempt as much as someone who is afraid of feeling pain and finds blood disturbing. Acquired factors, on the other hand, emerge over time as a result of numbing or habituation to various pain, fear, and death-related experiences. Finally, practical factors include knowing how to commit suicide or having access to lethal means such as firearms or lethal drugs, which make a suicide attempt more likely to succeed.

Cultural, Religious, and Spiritual Factors of Moral Injury and Veteran Suicide

To fully comprehend how moral injury can lead to suicide among US veterans, it is necessary to also examine the issue from a cultural, religious, and spiritual perspective. On the basis of a phenomenological and inductive analysis of a phenomenon, Jeff’s cultural, religious, and spiritual disposition will facilitate a deeper understanding of moral injury and suicide among other US veterans with a similar background. In addition, the 3ST will be applied to create a deeper understanding of Jeff’s situation. In addition, because the United States is ethnically, culturally, and religiously diverse, Jeff’s cultural, religious, and spiritual orientation will serve as a representation of many other US veterans with a similar background.

The Influence of Cultural Factors

Merriam-Webster (2023a) defines culture as the traditional values, beliefs, attitudes, and practices of a specific ethnic, religious, or social group. Jeff, like many other American veterans, has been influenced culturally by traditional American values such as patriotism and individualism, which in a working-class family include hard labor and a high level of personal responsibility. As a Marine Corps soldier, he has simultaneously been instilled with a strong sense of loyalty to his country, his superiors, and his peers. The military culture emphasizes respect for hierarchy and authority, which might cause soldiers to accept instructions from superiors without questioning them, even if they can cause them to commit transgressive acts. A strong sense of group loyalty can cause individuals to perform actions to protect each other, even if these actions may involve violating one’s own moral compass. Add to this the fact that battle fatigue and peer pressure can cause one to commit acts that conflict with one’s deeply held moral beliefs. In summary, Jeff’s cultural values include deep patriotism, individualism, and a strong military culture that emphasizes loyalty, respect for hierarchy, and group cohesion, which is typical of many other veterans.

The Role of Religious and Spiritual Dimensions

Merriam-Webster (2023b, 2023c) defines religion as the structured system of religious attitudes, beliefs, and practices of an individual or group, and spirituality as an awareness of religious principles and refers specifically to the condition of being spiritual. As part of a Lutheran family, Jeff has been influenced by Christian values including forgiveness, compassion, and love for one’s neighbor. When transgressions are committed, this can lead to internal conflicts in which one struggles to reconcile one’s actions with these fundamental values. However, during treatment, forgiveness and compassion can become crucial components of the therapeutic process. Jeff’s spiritual approach to life involved seeking a deeper meaning and understanding of his life and actions. Through introspection and self-reflection, this may initially deepen the connection with the inner conflicts and pain he experiences, as he allows himself to confront his actions and the associated strong feelings of guilt and shame, rather than disconnecting and attempting to shut off these sensations through the use of alcohol and drugs, as he did. In a later stage, however, his spirituality can lead to a process of reconciliation and personal growth, where he can gradually accept and process his actions, learn from them, and work towards making more congruent choices in the future. In this way, his spiritual beliefs and values makes him more resilient by serving as a foundation for understanding, coping with, and overcoming the conflicts that arise as a result of transgressive actions. In summary, Jeff’s religious and spiritual values are based on forgiveness, compassion, and love for others, and while these values may initially contribute to inner conflicts in response to transgressions, they may eventually be used in a therapeutic intervention to facilitate integration, reconciliation, and personal growth.

Applying the 3ST to Understand a Veteran with Moral Injury

Jeff’s cultural, religious, and spiritual values are analyzed through the lens of the 3ST of suicide, with a focus on how some of his values may act as protective measures, while others may increase the risk of suicidal ideation and attempts. The first step of the 3ST involves pain and hopelessness. With a strong emphasis on patriotism and individualism, Jeff’s cultural background may have initially contributed to a sense of moral superiority over enemies in the war zone. When Jeff returns to the United States and his ability to connect with his emotions improves, his religious and spiritual values conflict with his actions, causing him to view himself as an evil person.

Connectedness, the second stage of the 3ST, serves as a protective factor for Jeff. Despite engaging in self-destructive behaviors, he seeks assistance and support from close friends, which reinforces his sense of belonging and decreases the intensity of his suicidal ideation, preventing him from attempting suicide. Thus, Jeff’s extroverted personality and capacity to maintain social relationships are protective factors for his mental and emotional health. If instead Jeff was to isolate himself when feeling depressed and not seek support from close friends, his sense of connectedness would decrease, which probably would worsen his feelings of hopelessness and pain and thereby increase his suicidal ideation.

At the third stage of the 3ST, dispositional, acquired, and practical factors influence a person’s capacity to commit suicide. Due to his military training, experiences, and access to lethal means, Jeff is highly capable of committing suicide. However, his religious and spiritual beliefs may mitigate these risk factors by fostering hope and forgiveness, thereby decreasing the likelihood that he will contemplate suicide as a solution to his suffering.

A Personal Reflection on Moral Injury and Suicide among Veterans

Understanding the cultural, religious, and spiritual aspects of moral injury and suicide among US veterans is essential for obtaining a complete understanding of the issue. The case of Jeff demonstrates how these dimensions can contribute to both protective and risk factors associated with moral injury and suicide. Cultural values such as patriotism, individualism, and military loyalty can contribute to the occurrence of moral injury by fostering a sense of moral superiority and group cohesion that can lead to transgressions. However, these same values can also foster a sense of belonging and support, which can act as protective factors against suicidal ideation and attempts. In addition, religious and spiritual beliefs can initially worsen internal conflicts resulting from transgressive actions, but ultimately serve as a foundation for healing, personal development, and future resilience. By promoting forgiveness, compassion, and love for others, religious and spiritual values can provide a foundation for therapeutic interventions that facilitate veterans’ integration, reconciliation, and growth despite moral injury.

In summary, I believe that by understanding how cultural, religious, and spiritual values interact with suffering, hopelessness, connectedness, and suicidal capacity, as outlined in 3ST, clinicians and support networks can better assist veterans in managing and overcoming moral injury, thereby decreasing their suicide risk. However, after examining the existing research on moral injury in depth, an important question remains: Is it possible that a significant proportion of military suicides, which are currently attributed to PTSD, have a stronger connection to moral injury? As awareness of moral injury and its influence on the design of research studies exploring this phenomenon grows, it becomes increasingly urgent to investigate the actual effect of moral injury on veteran suicide rates. Nonetheless, my conclusion in therapeutic settings remains the same regardless of the outcome, namely that the power of being truly understood by someone cannot be overstated, especially when a person feels alone and believes they are a terrible person. This empathy can provide the necessary safe space for veterans to confront their moral injury, seek forgiveness, and ultimately transform their pain and guilt into personal growth and healing. 


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