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Identifying Coping Mechanisms for Veterans Suffering Moral Injury


The current ANS featured article is titled “Moral Injury in Veterans: Application of the Roy Adaptation Model to Improve Coping” authored by Michael Cox, DNP, MHA, RN; Vonda Skjolsvik, DNP, RN, CHSE; Becki Rathfon, MS, CCMHC; and Ellen Buckner, PhD, RN, CNE, AE. We invite you to download this article at no cost while it is featured, and return here to leave your comments and questions! Dr. Cox has shared his personal reflections about this article for ANS readers:

Michael Cox

The concept that one’s morally transgressive behavior may result in lasting harm to the individual’s well-being is thoroughly documented in historical literature, as ancient cultures struggled to explain and cope with warrior reintegration. In more modern times, Civil War soldiers were diagnosed with “soldiers’ heart” or profound melancholy. In WWI, the condition was described as “shell shock.” WWII introduced the term “battle fatigue,” and the Vietnam Veterans were diagnosed with Post Traumatic Stress Disorder (PTSD). However, mental health professionals are beginning to understand that these terms do not fully capture war’s moral and ethical implications. As a result, they fail to fully capture the soldiers’ challenges as they transition into civil society.

Shortly after the start of the wars in Afghanistan and Iraq, my military colleagues and I began to recognize the harmful effects of deployment. The concerns about our comrades’ psychological well-being escalated as current treatment modalities proved to be ineffective. The inability to explain our observations prompted us to refer to these soldiers “as broken.” Currently, 22 veterans commit suicide each day in the United States, and the rate of suicide among veterans 18 to 34 years of age has risen 80% compared to the civilian population.

Acknowledgment that the suffering of these soldiers does not resolve upon exiting the military; prompted our team to explore the concept of moral injury (MI) in relation to veteran suicide. MI is the damage done to one’s conscience or moral compass when the person perpetrates, witnesses, or fails to prevent acts that transgress one’s own moral beliefs, values, or ethical code of conduct. Our study describes the struggles veterans face as they try to reassemble their lives post-war.

Breaching moral boundaries has created dissonance between the veterans’ conscience and subconscious thoughts regarding right and wrong, resetting the individual’s fundamental identity and impeding their ability to develop relationships and maintain group identity. This inner struggle helps explain the previously determined feelings of betrayal, guilt, and irredeemablity frequently seen in veterans with MI. Unfortunately, I feel like I am reliving the past as the trauma experienced by our health care providers due to Covid-19 is manifesting in the same manner that we witnessed in those returning from deployment. It creates an environment where clinicians, similar to our veterans, struggle to reconcile the incongruence between their perceived ethical standards and those they are witnessing daily. Exploring the implications of this moral discord may be necessary to avert a similar crisis in our healthcare professionals. 

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