The Australian Defence Force (ADF) is one of Australia’s largest employers. Employing around 80,000 people, the ADF consists of three core branches: Australian Army (Army), Royal Australian Navy (RAN), and Royal Australian Air Force (RAAF). The core duty of the ADF is to protect Australian land, air, and sea, and the citizens who live within Australia. To perform this duty requires a collective mentality and adherence to predetermined codes of group behaviour. From recruitment, individual moral values are reimaged with military codes and values (Beneda, 2012; Molendijk et al., 2018). Individualism is replaced with collectivism through stringent military training regimes, a command structure, and ritualisation. Values such as a team-first ethos, honour, loyalty, and courage become deeply entrenched throughout military training and culture. Veterans are defined here as military personnel who “are serving or have served” (Parliament of Australia, 2019).
A veteran’s role is to listen, understand, and execute orders (MacLeish, 2018). Actions required of veterans can demand split-second decision-making. These decisions can affront existing moral frameworks resulting in moral injury (Currier et al., 2015; Shay, 2014). Moral injury can occur through self-directed (one’s own action or inaction) or other-directed (witnessing, or as a victim of another’s action or inaction) transgressions (Drescher et al., 2011). Literature on moral injury postulates that self- or other-directed violations of deeply held moral beliefs can cause several psychosocial challenges such as betrayal, guilt, shame, loss of meaning, loss of belief (e.g., spiritual, religious, world views), distrust, self-condemning behaviours, and heighten the risk of suicide (Bryan et al., 2016; Drescher et al., 2011; Farnsworth et al., 2014; Jamieson et al., 2020; Jinkerson, 2016; Jordan et al., 2017; Kelley et al., 2019; Litz et al., 2009; Nash & Litz, 2013; Shay, 2014; Wortmann et al., 2017).
In the ADF, suicide and self-harm causes more deaths and injuries post-service than in overseas operational service (Department of Defence, 2016). The number of veteran suicides in Australia has more than doubled from 19 in 2001 to 42 in 2017 (Australian Institute of Health and Welfare, 2019). Notable increases in military suicides have led to increased military suicide research globally. Traditional military trauma and suicide research has predominantly focused on post-traumatic stress disorder (PTSD). Contemporary theorists are now exploring moral injury and its links to suicidality (Bryan et al., 2018; Carey, Hodgson & Cohen, 2016; Jamieson, Usher et al., 2020; Jamieson et al., 2020; Jinkerson, 2016; Jordan et al., 2017; Kelley et al., 2019; McCarthy, 2016).
Most research into moral injury stems from the USA and has been military-focused (Bryan et al., 2016; Drescher et al., 2011; Griffin et al., 2019; Koenig, 2018). However, non-military sectors, such as first responders, police, and healthcare personnel, can also be affected (Ford, 2019; Haight et al., 2016; Murray & Gidwani, 2018). More recently moral injury research has surged due to the links between healthcare personnel and moral injury during the COVID-19 global health pandemic (Dean et al., 2020; Haller et al., 2020; Williamson et al., 2018).
Globally, the prevalence of moral injury remains unknown. Therefore, assumptions about presentations of moral injury would need to be carefully considered until a suite of rigorous and robust tools become available to determine the population affected. There has also been limited exploration into treatment approaches for moral injury. Therefore, more research is needed.
As a contribution to the field, this study explored how participants narrate their experience of moral injury post-ADF service and what mechanisms supported them whilst living with moral injury. This paper’s purpose is to build knowledge derived exclusively from veterans’ perspectives. Outcomes from this work could assist with the development and delivery of more appropriate veteran support. This paper focuses on the theme “walking forwards with moral injury” that explores how participants make meaning of their experiences of living with moral injury post-ADF.
A qualitative design was deemed most appropriate to address the research aims of examining how veterans narrate their experiences of moral injury post-ADF service, and what mechanisms supported them when living with moral injury in Australia. This approach is considered useful in researching complex human science and behaviour such as moral injury (Finlay, 2011; Liamputtong, 2009; Leavy, 2014; Walter, 2006, Webster & Mertova, 2007). The first author’s own networks, social media, and purposive and snowball sampling methods were used to recruit former members of the ADF who met the study’s inclusion criteria: that participants had left the ADF, had identified as having experienced moral injury and previous suicidality, and were able to converse freely in English and participate in a face-to-face in-depth interview. A brief pre-screen questionnaire was conducted prior to the interview to determine participants’ eligibility (Brace, 2018). Participants who were experiencing severe psychological symptoms (e.g., severe nightmares, flashbacks, suicidal ideation, plans, and or/attempt) as well as those who did not meet the inclusion criteria were excluded. Ethics approvals were obtained in 2018 from both the Department of Defence and Veterans’ Affairs Human Research Ethics Committee (035-18) and the University of New England Human Research Ethics Committee (HE18-218). Eligible participants were provided with study and consent information as well as Guidelines for Volunteers from the Department of Defence and Veterans’ Affairs Human Research Ethics Committee. A list of resources outlining several mental health resources was also provided.
In-depth interviews were chosen to acquire an understanding of participants’ perspectives of their lived experiences (Minichiello et al., 2008). Interviews lasted on average two and a half hours and were audio recorded and transcribed verbatim. Transcriptions were then sent to participants for review. All were returned without edit. Transcripts were manually coded using highlighting and hardcopy transcripts. Transcripts were then electronically coded, first using Microsoft Excel then Quirkos© data analysis software. Thematic analysis was undertaken using Braun and Clarke’s (2013) thematic analysis framework. Themes were then cross-referenced with the supervision team and co-authors. Findings are reported following the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (Tong et al., 2007).
Eleven participants, seven males and four females, from Queensland, New South Wales, Victoria, and the Northern Territory agreed to participate in the study, with a combined total of 86 years of military service experience across the three core branches (see Table 1). All participant quotes used are provided verbatim and numbers were allocated for confidentiality and to protect the identity of the participants.
|PARTICIPANT||AGE||YEARS IN SERVICE||BRANCH||DEPLOYED Y/N||IDENTIFIED GENDER (M/F)|
The findings of this study summarise participants’ experience of living with moral injury as a civilian post-ADF. One overarching theme and three inter-related sub-themes were identified from the data (Table 2). Whilst each theme is discussed separately, they are also interwoven, resulting in a better understanding of how participants navigated their life post-ADF with moral injury.
|WALKING FORWARDS WITH MORAL INJURY|
|1||Meaning-making and moral injury||Describes the importance of understanding through validation, acceptance, and reconciliation|
|2||Narratives of transformation||Describes narratives of personal change and growth|
|3||Leading the charge||Describes the importance of helping others|
The notion “walking forwards” emerged from the desire, drive, and motivation that participants described when discussing how they navigated their new normal. The term “walking forwards” was first described by Participant 5 when discussing how moral injury affected them post-service:
I think moral injury is not something you get better from, it’s not something that you can sit in a therapist or see a psychiatrist and get drugs for, or see a psychologist and get CBT [Cognitive Behavioural Therapy] for, it’s not that. Moral injury is about assisting a person to empower themselves, to pull that shattering back together into a story they can walk forward with.
Participant 5 described the ability to both name the experience and accept moral injury became part of their new normal, enabling them to walk forwards whilst living with moral injury. Similarly, participant 3 said, “… accepting that I have got this, but it’s not going to kill me, my life isn’t over, and I can grow from it,” highlighting their journey of acceptance and willingness to continue to walk forwards in life, providing they have the right mechanisms in place to support their journey.
In order to manage and accept their new normal, participants described undergoing a variety of processes to help them make meaning of their experience and re-establish themselves. This theme describes how participants made meaning of their experience, highlighting important factors in their meaning-making journey. When examining the individual narratives, a common thread of loss was revealed. Participants described losing their military identity: “… it seems that, you know, it takes away who you are, what you can do, you know, it takes away your career. The Army’s your whole life” (Participant 6). Others described how losing their military identity heightened other areas of loss in their lives:
I have lost who I was as a soldier, don’t like who I am turning into. I’m failing as a parent and husband—wife will leave you; you will never see your wife and kids; you will lose your house—was all going through my mind. So, I didn’t feel there was much point being here, so I started to consider means of suicide. (Participant 4)
For all participants, these losses were wide-ranging and devastating, including the deaths of colleagues or friends, loss of relationships, finances, career, and identity. All participants provided examples of their losses but indicated identity loss was the hardest to reconcile:
I have lost a good decade— probably longer—of a career and it’s not just that loss of career. It’s that loss of life trajectories, you know, everything that comes with it, employment, financial stability … marriage and children, everything. (Participant 9)
Through these losses, participants discussed how eventually they began to make sense of their loss, describing several processes that helped them to do so.
Participants described emotional, moral, and ethical challenges with orders that were against their moral beliefs or did not make sense to them. For example, Participant 4 described his internal struggle with guilt and shame following an order that consequently resulted in significant injuries to a colleague, saying: “I should have said more, I should have done more, I should have fought harder for the boys.” When such events occurred, participants described needing these experiences to be validated “I just wanted an acknowledgement, I just wanted someone to say, ‘I understand, and I believe you, I believe that this happened to you, and I’m sorry’” (Participant 9).
For female participants, the need for validation of their negative experience was more prominent, highlighting the potentially gendered differences relative to moral injury. Women reported a lack of compassion or support: “There was a complete lack of care or understanding of you know … I haven’t really felt support by anybody really, I guess some of that is the lack of connection or a willingness to understand” (Participant 5). In contrast, male participants focused on the need for validation directed towards specific roles, actions, or positions within the ADF. Both genders described needing validation from external sources, especially from their leaders and government services for veterans. What was commonly experienced for participants was a need for the recognition of and validation of their mental health needs when they arose. However, few experienced this sense of recognition and validation, therefore opted to avoid accessing support through fear of career limitation and stigma. Instead, participants often looked to each other to validate their experiences and feelings: “We were the first to experience loss on our trip. So, when it happened, and it happened to mates, we sort of took, like a guidance, helping-type role and acknowledge what they had been through” (Participant 3).
Participants were often left questioning their experiences, searching for valid reasons to be able to accept their experience, for example partaking in deployments that resulted in many deaths or injuries. As participants 3 and 5 described earlier, their acceptance of their moral injury as their new normal, providing a sense of reconciliation for them. Participant 1 also described how acceptance helped him to reconcile his experiences and commence the meaning-making process stating:
I’m healed as best I can but by doing, I take fucking ownership of it. No, but this one thing I learned. You need to be entirely responsible for everything that you do and your own journey in rehab, whatever.
Taking ownership requires courage and reconciliation. Here reconciliation is used to describe the process veterans used to reconcile their identity and experiences of loss. When reconciliation is achieved, a renewed sense of focus and confidence can follow. Participant 1 wanted to reconcile his perceived or actual inaction that underpinned his moral injury, saying:
I have been to every single one of the boys’ houses and apologised to them, you know, I was just something I had to do … I just felt like I morally had to do a responsibility, you know.
Participants described a desire to walk forwards, and in doing so, knew that changes were required. These changes started with acceptance, validation, and reconciliation that often became the catalyst for future growth.
Narratives of transformation describes the process of reframing, reclaiming, and repurposing participants experiences to help them move through life with moral injury. Military transformation was the process of intensively training individuals to defend the nation, instilling values such as loyalty, collectivism, commitment, and honour. However, after service, the transition back to a civilian was problematic: “They’re good at training people to do one thing and they’re shit in helping anyone do anything else, or recover, and transition is awful” (Participant 1). Transitioning from the ADF is often beset with challenges and can be morally traumatic, and negatively impact upon mental health: “I got diagnosed with adjustment disorder, mixed anxiety, and depression, alcohol and opiate dependence” (Participant 1). Some participants suggested needing the time to “unfuck yourself and have a little bit more of a relaxed wind-down” in doing so they can then: “sort yourself out and reset” (Participant 11). Post-ADF transformation differed for each person, however, the processes of reframing, reclaiming, and repurposing of their experiences were emergent as necessary components for a “reset” and transformation to occur.
During this process participants began to reframe the negative aspects of their experience and reclaim the positive ones, finding new ways to express them in their new civilian identity. When reframing, the facts of the experience remained the same, but the way participants viewed it was shifted: “I wouldn’t have possibly learned the life lessons I’ve learned if I hadn’t been in such a shit environment” (Participant 8).
For many, the reclamation of their new identity was about goodness (i.e., doing good or feeling good about themselves). For Participant 2, after years of bullying, when reflecting on her journey she reclaimed her experience, saying, “it’s put me on a path that I’m on now … I started doing some post-grad study … has changed my life.” Reclaiming their identity also helped participants to counter any feelings of failure, hopelessness, and worthlessness, helping them to understand their own journeys, and providing an opportunity to learn and grow from their experiences:
So, it’s actually reclaiming that and recognising my story. You know, I have lost a good decade—probably longer—of a career and it’s not just that loss of career, it’s that loss of life trajectories, you know everything that comes with it, your employment, your financial stability, everything. (Participant 5)
To repurpose is to take one thing and reuse it as something else. The search for repurposing was personal for participants and followed reclamation. Participants shared their feelings of uselessness, and how they no longer felt a sense of meaning and purpose. Despite significant challenges for all participants when leaving ADF service, stories of hope through re-finding purpose were described:
Most of all is something to focus on or somewhere, you know, something that, like a light at the end of the tunnel, just something that I could move towards. You know, something to give you purpose. (Participant 6)
For some, finding secure employment very quickly gave them purpose: “When I got home, I bought my family’s business out of liquidation, which gave me a job to leave … and my four years was up, so made it an easier path out” (Participant 3). Repurposing could also be in the form of taking on a new hobby, ceasing to self-medicate, advancing education, or training their mind to think differently:
I’ve set programs in place for recovering veterans and had really well-documented results on the benefits of free diving, you know, because it changes the way your brain works … all the noise stopped when I was underwater. (Participant 8)
Participant 1 discussed how growth was a key feature in their repurposing journey, saying, “I’m going to … period of growth, through it, and the stuff I’m doing now is all … is a result of all of this happening, you know, so this has really been, like, the defining feature of my life” (Participant 1). Participants described how they made meaning of their experience and then used their experience as a platform for transformation through processes of reclaiming, reframing, and repurposing. This transformation helped participants to continue to walk forwards. Helping others and creating positive change became the primary repurpose tool for participants.
The last theme that emerged focusses on leading the charge. Leading the charge refers to the ways in which positive change occurred for participants. From a military perspective, leading the charge means inspiring others to follow, even while the terrain may be treacherous. Here, leading the charge can be equally as treacherous, yet ultimately resulted in participants deciding to approach life differently, taking charge of their lives, and occurred when participants had reclaimed and repurposed their identity. While participants spoke of the impacts from their military experiences, all described engaging in activities that helped them repurpose and transform and continue to walk forwards in life. Participants described incorporating healthier practices that they previously did not have:
I can tell you right now, exercise and meditation, without a doubt … when I am exercising daily and practicing meditation at least once a day for half an hour, it’s the best I have ever been since the thing (moral injury). (Participant 3)
The ultimate resolution for participants was helping others to lead their own charge out of the military and into new ways of living.
All participants described repurposing their experiences as a vehicle to help others: “I think I was made to experience it so that I could go and be used as a tool of healing for others” (Participant 8). Similarly, Participant 8 described how he helped others saying: “I wrote a book to help, a thing that took me 10 years to figure out might help others.” Others were keen to share their stories to encourage others to come forward:
Biggest thing I picked up was that no-one ever talks about it and the people that did talk about it were usually the ones that told somebody else’s story, so I made it a valid point that I was going to be completely open about my experiences. (Participant 3)
All participants noted how participating in studies such as this were fundamental to the repurposing of their experiences. The need to reclaim and repurpose was important in transforming participants lives, through providing purpose and meaning. Yet for some, simply finding their voice was a way in which to lead the charge: “I’m trying to be a voice for those who might not be able to” (Participant 10). This was especially pertinent for female participants, who often discussed feeling voiceless in their military experience: “I never had a voice; I have a voice now. And it’s about how you use that” (Participant 5).
The message of helping others was often discussed, for some helping others was through targeted advocacy with participants describing a need to appeal for changes to stop actions or behaviours that had negatively impacted themselves or others:
I still feel wholly responsible for what happened to the other boys. You know, that was the … I mean, like, I don’t really care about what happened to me too much, at least that’s within … I can deal with all that, you know, I have support and I’m looked after, but the other boys are not, so I got on my high horse about this and started going to politicians and senators. (Participant 1)
For others this was described as a desire for systemic and organisational change:
So, for me it’s not about blaming Defence [ADF], not blaming anybody, it’s about: ‘So how can you change the system so other people don’t have to go through this?’ is the most significant for me. (Participant 5)
Throughout the narratives of walking forward with moral injury, participants made several suggestions that they believed would have helped them and or would help others who may be facing or have faced similar circumstances. The most provided advice was the need for positive and authentic alliances. Veterans can often feel stigmatised when seeking support, particularly if previous experiences were negative and created feelings of distrust and withdrawal for them. They often rely on recommendations from other veterans before help-seeking. Positive alliances with others (e.g., trusted health providers, veterans, and non-veterans) was an integral part of the participants’ transformation journeys. Participant 6 noted the importance of building good relationships with clinicians highlighting his experience of one clinician, saying “… could not speak highly enough, even the boys, a lot of the boys, have followed her out to her civvy practice. She gives a fuck!” An authentic alliance is critical for veterans and can determine whether a veteran continues with treatment or not. For Participant 9, “having people that genuinely sit down and talk to you and care about you” was the most crucial factor when seeking support.
All participants described experiencing problems either accessing or participating in appropriate therapeutic support, both in and out of service. Some expressed the need for flexible, alternative approaches, such as methylenedioxymethamphetamine (MDMA) trials (Participant 3). Participants 9 and 11 also explained the importance of alternative methods, and how flexible, multi-modal support benefited them: “I was at this health retreat thing … I was exposed to art therapy, music therapy, equine therapy, so there were other avenues I could express myself” (Participant 9). Participant 11 described the benefit of using the Soldier Recovery Centre: “So I did the six … the six-week program there, and that, that was absolutely awesome”.
The need for appropriate peer support and practical help to re-establish their identities as civilians were commonly described. Participant 11 stated:
… talk to other people, you do some courses, so you have time to unfuck yourself and you have some appointments with people, and they teach you mindfulness and meditation and assist you, and where there’s other veterans and where they assist you with helping you write a resume.
The themes above outline how participants narrated their experience of walking forwards with moral injury. Feeling validated and understood is important for meaning making. Meaning making is integral for acceptance and reconciliation, without these, the process of transformation could not occur. The process of helping others and advocating for change was also an essential component in many participants transformation journeys.
The purpose of this study was to explore participant’s experiences of living with moral injury and how they made meaning of those experiences. Three themes were developed that revealed the central role of meaning making, the capacity to transform through acceptance, and validation and using transformation to support and advocate for other veterans.
The findings of this study offer three conclusions that provide insight into what has been garnered from participants’ stories. The first conclusion is that all participants had experienced a moral injury resulting from either actions or inactions (by oneself or others), but particularly from those in positions of power, for example, chain of command or clinicians. Their moral injury manifested through feelings of betrayal, distrust, anger, shame, guilt and self-condemning thoughts and behaviours including suicide behaviours, aligning with contemporary moral injury literature (Ames et al., 2019; Brock et al., 2012; Bryan et al., 2018).
The second conclusion focusses on identity and the importance of meaning-making to enable participants to understand and improve their self-identity (Currier et al., 2015; Moon, 2016; Smith & True, 2014). Research into military identity states military personnel frequently view their military identity as their dominant one (Higate, 2001; Lancaster et al., 2018; Smith & True, 2014). Recent advances in identity theory suggest that the purpose of self-identity is as a value and meaning-making agent, and for information processing (Baumeister & Landau, 2018). Therefore, when one’s core identity is threatened, especially if founded in trauma such as killing or military sexual abuse for example, a person’s meaning-making agency and self-identity can also be damaged (Beneda, 2012; Jones, 2020; Vargas, 2012). Such damage can heighten the risk of negative feelings and suicide behaviour in veterans (Farnsworth et al., 2014). When examining the development of stories across each interview, it seemed that veterans may also be experiencing feelings of inadequacy. They described the problems they faced relative to their feelings of inadequacy or the inadequacy of others. Scholars have linked these feelings of inadequacy to the mental and physical wounds veterans may have suffered, any stigma that may be associated with the wounds, or with military service in general (Blevins et al., 2011; Sayer et al., 2014). Thus, how veterans make meaning of their experience is an important consideration in suicide prevention approaches.
The third conclusion is that transformation is possible, presupposing several important considerations. For transformation to occur, acceptance, reconciliation, and validation are needed. Acceptance and reconciliation were multi-layered for participants; first, they had to accept themselves in their new identity, in doing so meant accepting what others or they themselves had done or not done. This is not to say that acceptance meant healing: quite the opposite, as participants described moral injury as being lifelong and something one learns to live with. Their acceptance was based on navigating and reconciling their self-identity journeys whilst living with moral injury (Brock, 2020). Reconciliation on the other hand, is a global, universal, and multidimensional reality that can help to reconstruct a person’s self-identity (Lee, 2018; Samson et al., 2015). Trauma theorists postulate that acceptance is a key part of the reconciliation journey (Lee, 2018, p. 73). Through their narratives, veterans perpetuated the values and ideals of the culture of which they were a product and described their difficulties in trying to reconcile these ideals with the civilian cultural identity they now found themselves living. Moral injury is difficult to articulate and often goes unvalidated, hindering treatment approaches. Moral injury, therefore, can only be accepted and validated when: “the individual is permitted and empowered to voice their experience; the listener is allowed to listen, believe, and remember; and the listener is allowed to repeat what they have heard to others” (Meyer et al., 2018, p. 1274).
For those interviewed, re-finding purpose was also pivotal to the transformation of their identity. Held et al. (2019) identified re-finding purpose as a way of ascribing redemptive meaning to injuries and suffering. However, the identity journey was not straight forward, there was not one pivotal moment in their lives that drove them from severe identity difficulties into a life filled with purpose and meaning; in fact, it was quite the opposite. Participants described their battles with drug and alcohol misuse, relationship difficulties, and financial difficulties, describing how they had often sought treatment or had been encouraged to seek treatment. For some, the treatment (e.g., psychologist) helped them to walk forwards again. However, many reported adverse experiences. The nature of service in the ADF results in a sense of kinship between veterans; however, this can also make help-seeking difficult beyond veteran-specific services for structured support as well as among veterans for social support. The process of looking for a community to belong to after service was common. Usually, this began with reconnecting with other veterans, producing an immediate kinship because of their shared defence experiences, and using peers for support and validation. The participants in this study identified that frequently their support was found outside their professional psychotherapeutic help, rather via other veterans or veteran-centric support networks. This is an important finding for future treatment and practice approaches.
The stories of every participant revealed how exiting the military meant restarting their new life as quickly as possible. These women and men were intensively trained to keep moving forward. They described how they moved rapidly from an important, highly trained, goal-directed, and regimented environment to an isolated and alien environment where they were unable to support themselves or their families. These significant changes resulted in increased mental health problems and suicide risk (Corona et al., 2019).
The study found that to continue walking forwards, positive transformation was required. This transformation occurred through understanding and validating the meaning ascribed to participants’ identity and then reconciling the experience. However, to date, very little research has adequately explored how to support veterans through these processes. Despite the challenging experiences described, participants’ drive for purpose and change was a catalyst for walking forwards. They were able to see how they were living and made changes that often meant becoming involved in activities not previously engaged in. For participants, these activities included participation in advocacy, alternative therapeutic approaches, and public speaking. This drive for purpose and helping others served as a key protective mechanism for participants. Further research would benefit from exploring this area in more detail.
As with most studies, limitations exist. Here, the study sample size was relatively small, therefore, findings are not generalisable. It is acknowledged that the researcher’s background and loss of a veteran son to suicide may have inadvertently influenced veteran responses in some way. All participants were Australian, with a higher male-to-female ratio. Participants were recruited mainly from metropolitan areas where there are more psychosocial supports available. Demographic differences may have resulted in different outcomes. Participants were more likely to be comfortable in telling their stories across a variety of forums. Further research is needed to ascertain similarities or differences across other groups and demographics.
The study addressed the aims of examining how veterans narrate their experience of moral injury post-service, and what mechanisms support veterans living with moral injury in Australia. The findings from this study add another dimension to the moral injury literature. By using participants’ lived experience, a plethora of evidence that supports the study aims has emerged with implications for future clinical practice. Scholarly recognition has been given to understanding the lived experiences of veterans, however previous consideration had not been shown to this select group of Australian veterans. Until the completion of this study there was no Australian literature that described the contextual and motivational factors of veterans living with moral injuries. Now that we have evidence to substantiate their experiences, it is timely to consider how we can use these outcomes to inform future policy and practice.
Reshaping identity includes processes that are often embedded in one’s cultural, familial, and spiritual backgrounds. The integration of religious or spiritual practices within traditional trauma-related modalities may be pertinent and timely to the treatment of moral injury (Currier et al., 2019; Drescher et al., 2013). However, clinicians may not be accustomed to the impacts of moral injury among veteran clients. Common tests and procedures do not yet adequately assess anxiety or trauma stressors include betrayal, which is a key antecedent and attribute of moral injury (Jamieson Maple et al., 2020). It is important for all who work or engage with veterans to understand the veteran context and population, and how their training, conditioning, and service exposure can lead to both betrayal and the development of moral injury. Additionally, it is beneficial for clinicians to understand the core constructs and implications of moral injury fully, as well as understanding what works for veterans with moral injury. This paper provides useful signposts for clinicians and those working with veterans to use when navigating and supporting veterans with moral injury.
Department of Defence and Veterans’ Affairs Human Research Ethics Committee: 035-18 approved 10 July 2018–9 July 2020. University of New England Human Research Ethics Committee: HE18-218 approved 6 September 2018–30 June 2020.
This research received funding from Suicide Prevention Australia and the Research Training Scheme Scholarship.
The authors have no competing interests to declare.
All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/recommendations/)]: substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content.
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