Relationships among Combat Experience, Moral Injury, and Mental Health Outcomes

By Leanne Komnick Psy.D.

Nearly two million military members have deployed in support of the continued conflicts in Iraq (Operation Iraqi Freedom, OIF) and Afghanistan (Operation Enduring Freedom, OEF) and Operation New Dawn (OND) (Campbell and Riggs 2015). We as a society have become more aware of the effects of war. For example, we know that military members who have engaged in combat are far more likely to be diagnosed with post-traumatic stress disorder (PTSD), anxiety, and depression. Yet there are many unanswered questions related to the psychological treatment and interventions developed for those who have served in the Armed Forces as well as the reduction and prevention of the completion of suicide in this community. The current statistics state that twenty-two veterans a day die from suicide (Department of Veterans Affairs 2017). This body of work is dedicated to the impact that war can pose on those who have served in the Armed Forces and aims to shine a light on the impact that moral injury can pose.

• Language: English
• Publisher: Newman Springs Publishing, Inc.
• Release date: Sep 6, 2023
• ISBN: 9798890610010

Book preview

Table of Contents

Title

Copyright

Acknowledgments

Abstract

Introduction

Literature Review

Methods

Figure 1. Proposed model for impact of combat deployments.

Results

Discussion and Conclusion

Appendix A: Definition of Terms and Acronyms

Appendix B: Demographic Questions and Deployment History

Appendix C: Moral Injury Symptom Scale-Military Version (Long Form)

Appendix D: Deployment Risk Resiliency Inventory-2, Section D

Appendix E: Deployment Risk Resiliency Inventory-2, Section E

Appendix F: Patient Health Questionnaire-9

Appendix G: Post-Traumatic Stress Disorder Checklist for DSM-5

Appendix H: Suicide Behaviors Questionnaire-Revised

Appendix I: Online Consent Form

Appendix J: Recruitment Message

Appendix K: Self-Disclosure Serving in the United States Air Force as a Mental Health Technician

Appendix L: Email for Permission to Use the Moral Injury Symptom Scale-Military Version

Appendix M: Email Response from Dr. Koenig

Appendix N: Flyer

Appendix O: Tables

References

About the Author

List of Tables

List of Figures

cover.jpg

Relationships among Combat Experience, Moral Injury, and Mental Health Outcomes

Leanne Komnick, Psy.D.

Copyright © 2023 Leanne Komnick, Psy.D.

All rights reserved

First Edition

NEWMAN SPRINGS PUBLISHING

320 Broad Street

Red Bank, NJ 07701

First originally published by Newman Springs Publishing 2023

ISBN 979-8-89061-000-3 (Paperback)

ISBN 979-8-89061-001-0 (Digital)

Printed in the United States of America

To my brothers- and sisters-in-arms—past, present, and future. Signing up to join the military is a selfless act regardless of the reason/motivation behind it, whether it is money for college, a family tradition, or a way out of your current situation. I am deeply indebted to the United States Air Force for guiding my current passion to help military members and veterans in their mental health journey. The United States Air Force provided me with stability, routine, and discipline and built upon my own resilience and grit. My hope for my brothers- and sisters-in-arms is for them to know that many people are fighting for them as they fight for our freedoms. Your dedication and sacrifices do not go unnoticed and can never be repaid.

In loving memory of all of our brothers and sisters who have been through hell and paid the ultimate sacrifice and those who returned from combat or military service physically but mentally were never the same. And most importantly, for my brothers and sisters who gave in to the war within. You are remembered and continue to guide your brothers and sisters from above.

Most of all, I would also like to dedicate this body of research to my inspiration for joining the United States Air Force: my grandfather Major Lyndon O. Marshall. Thank you for being our hero.

Acknowledgments

First, I want to acknowledge my mentor, Dr. Polly Lytle. Without you, your guidance, and your support, I would not have made it this far in this program.

Dr. Rhoda Olkin, thank you for your guidance, expertise, and support during this process and during our time of transition.

Dr. Quyen Tiet, thank you for your guidance, encouragement, expertise, and passion for military members and veterans.

Finally, I would like to acknowledge my children—Josiah and Christian—who were three and five years old when I began this journey. You have sacrificed a great deal in this process, and it does not go unnoticed. You have been my inspiration and reason to keep going in times I questioned whether this journey was truly worth it. We have missed out on a great deal of time together, and my hope is that you will understand and be proud one day when you're older. I love you both so much, my Siah and my Stinky!

Abstract

Military members who have engaged in combat are far more likely to be diagnosed with Post Traumatic Stress Disorder (PTSD), anxiety, and depression. But we don't yet know why some military members develop mental disorders and others do not. There remain questions as to how to best treat returning members suffering with the psychological and emotional wounds sustained from battle, such as moral injury and the link between moral injury and increased risk associated with suicidality.

The present study collected quantitative data regarding the impact of combat exposure and its relationship to moral injury and mental health outcomes, in a nonclinical sample of forty-nine military members. The two groups were divided into the following: (1) military personnel and veterans exposed to combat and (2) military personnel and veterans who deployed and did not experience combat and those having never been deployed. The hypotheses tested were the following: (1) deployment status and combat exposure will lead to higher mental health diagnoses and suicidality and (2) deployment status and combat exposure is a predictive factor for moral injury. Findings did not support either hypotheses, perhaps in part because of a small sample size and the combining of the two groups (military without combat and nondeployed) into one group.

Additional research is necessary in the realm of military and combat experiences; their relationship to moral injury; and effective ways to screen for, diagnose, and treat moral injury.

Recommended next steps would be a comparison of all current measures of moral injury among one another to determine which measure is able to capture moral injury and its symptomatology with accuracy, integrating qualitative data with quantitative findings and a correlational analysis of moral injury and suicidality as well as the use of the Moral Injury Symptom Scale in pre- and postdeployment processes. This would help determine a baseline of military personnel's moral functioning, shed insight as to whether an individual has already experienced a moral injury, and aid in narrowing down the potentially morally injurious events (PMIE) the individual has experienced in their military career. This body of research is important in providing future directions of research on military experiences, combat experiences, moral injury, and mental health outcomes.

Introduction

Nearly two million military members have deployed in support of the continued conflicts in Iraq (Operation Iraqi Freedom, OIF), Afghanistan (Operation Enduring Freedom, OEF), and Operation New Dawn (OND) (Campbell and Riggs, 2015). More than 1.09 million service members who served in OIF/OEF have separated from the military from 2001 to 2009 and now are considered veterans (VA Office of Public Health and Environmental Hazards 2010). Veterans who served during the OEF/OIF period of time continue to be diagnosed with PTSD, anxiety, and depression at alarming rates (Soldiers' and Marines' Mental Health, Congressional Digest 2007).

We as a society have become more aware of the effects of war. We know that military members who have engaged in combat are far more likely to be diagnosed with post-traumatic stress disorder (PTSD), anxiety, and depression. However, we are still left with many unanswered questions. For example, we have yet to answer why some military members develop mental disorders, such as those listed above, and why others do not. We are also left with questions as to how to treat returning members suffering with the psychological and emotional wounds sustained from battle.

Current statistics state that twenty-two veterans a day die from suicide (Department of Veterans Affairs 2017). Recent government reports are finding that suicide in the veteran population is twice as likely to occur in comparison to the civilian population (Simkins 2019). This number only accounts for suicide completions and does not account for the number of attempts that take place daily. The suicide rate among the military and veteran community is astounding and continues to rise. Military members are exposed to multiple stressors associated with heavy workloads, high expectations to perform primary and extra duties of mission-related needs, separation from families, exposure to trauma, and navigation of their chain of command (Stetz et al. 2006). PTSD and moral injuries are similar to each other, but moral injuries may pose a bigger impact in relation to the suicide rate (Shay 2012).

Military members returning from combat and veterans who have served in combat are coming home and facing a myriad of health problems related to their deployments. The most prevalent of these health problems faced by combat veterans are post-traumatic stress disorder (PTSD), major depressive disorder (MDD), and increased drinking (Cigrang et al. 2014). While we know that combat deployments are associated with a much higher risk of developing PTSD, we may not be evaluating all the factors that are contributing to the negative health effects associated with the aftermath of having been exposed to combat.

Military members and veterans who have served in combat face difficulties when returning home, which is referred to as the reintegration process. Reintegration is the process of resuming the life and duties that the member held prior to deployment. Some of the difficulties associated with reintegrating can be obvious if the member was exposed to long-term combat and faced traumas such as being shot at, having to shoot at others, or witnessing death(s). Service members also report experiencing difficulties with interpersonal relationships with family, friends, and children, among others, when returning home from deployments (Cigrang et al. 2014).

Military members exposed to combat deployments report it is difficult to relate to their loved ones and friends when returning from combat (Cigrang et al. 2014). Combat veterans are reporting that it is easier to relate to others they were deployed with or others who have shared similar experiences. Interpersonal relationships are a significant protective factor when evaluating veterans and service members for suicide risk (Cigrang et al. 2014).

Improving pre- and postdeployment processes made available to service members and veterans is crucial. Striving to understand what specifically is impacting combat veterans in relation to their deployment experiences is as equally important. Improvements to pre- and postdeployment processes and gaining a better understanding of the impacts of deployment could aid in the treatment and prevention of mental health-related injuries such as PTSD and MDD and hopefully aid in decreasing the current suicide rate of military members and veterans.

Military members returning from combat often speak to the guilt and shame they feel because of the acts of war they witnessed or participated in during their time spent in war. War will often require individuals to act in ways that they normally would not. War also insinuates that one's own life may be in jeopardy at any given time. Oftentimes, the guilt and shame that remains when returning from war is associated with the witnessed atrocities and acts in which they may have participated and how these actions go against the individual's own moral beliefs (Minear 2014). Essentially, this can cause persons to question their sense of morality.

While there have been research studies examining the negative implications and behaviors because of deployments, there has been little research done to examine the relationship between deployments and the threat they pose to individual morality or the incurrence of moral injuries. Further research is needed to better understand the impact that deployments pose and whether this impact is linked to or exacerbates the likeliness of incurring moral injuries and how moral injuries may, in turn, impact returning combat veterans suicidality.

The purpose of this dissertation is to examine the relationship between combat deployments and the impact on a person's beliefs of what is right and wrong (moral compass) and how engaging in actions and behaviors that go against one's moral beliefs may create lifelong impact on an individual. One way to examine the development of morality and combat's possible impact on one's morality is through considering theory and previous frameworks and studies of moral actions and regressions such as Stanley Milgram's (1963) experiment on obedience to authority figures as a way to understand how combat, war, and authority may impact military personnel's behavior and actions while deployed. Milgram paved the way to understanding how one may act differently, being willing to shock another human being to appease authority figures (Milgram 1963).

Literature Review

This literature review will include morality, war, military culture, military values, the Law of Armed Conflict, and the Geneva Conventions. Additionally, I will examine the impact that military leadership and the Commander in Chief (president of the United States) pose on military members. War crimes and the presence of private military groups and mercenaries will be examined to assess what impact these factors may pose to active-duty military members in a deployed location. These topics are examined to explore the following: (1) how combat deployments may impact an individual's sense of what is right and wrong (moral compass); (2) if the individual had to go against their own moral beliefs while participating in war (moral injury), how these actions are reconciled when the veteran is no longer in combat; and (3) if negative impact to one's moral compass increases risk for mental health diagnoses and suicidality.

Definition of moral compass

All human beings have a moral compass (Gray 2010). According to dictionary.com, moral compass is defined as an internalized set of values that guide a person to ethical behavior and decision-making. A moral compass is individualized and unique to each person. Morality in itself is a construct of values that is passed down through society, religion, familial/cultural values, and personal values (Damon and Lerner 2008).

Moral judgment (moral compass) can become compromised in the face of moral dilemmas (Marshall, Watts, and Lilienfield 2018). The basis of this dissertation is the evaluation of how the continuous exposure to war can impact a person's moral judgment. For some people, war in itself can induce moral conflict. For members of the military, they may face moral conflict in the face of war but will still be expected to carry out the orders of the mission. Members of the military will not have a choice in their level of participation in war. They can face disciplinary action if they do not carry out orders given to them, even if these orders go against their own moral beliefs.

There are many layers to the development of one's moral judgment. Moral judgment can also be influenced by fear and authority figures (Marshall, Watts, and Lilienfield 2018). When one has no other choice but to act in a way that goes against their own moral beliefs, it can cause what is known as a moral injury. Moral injuries are becoming more prevalent among combat veterans (Shay 2012). To understand moral injuries and how deployments (circumstance) can impact one's moral compass, we must first define what morality means and seek to understand how we as human beings develop a sense of morality in the first place.

Definition of moral injury

Moral injury is closely linked to symptoms of post-traumatic stress disorder (PTSD) (Litz et al. 2009). Both moral injuries and PTSD have similar criteria and require witnessing a triggering event, the reexperiencing of the event, avoidance, and physiological arousals (Shay 2012). What differentiates moral injury from PTSD is the role that is played during the event. In moral injury, the person could also be a perpetrator in the event and not just a victim or a witness. Another key differentiating factor are the emotions that are tied to the event(s). Emotions associated with moral injury are guilt, shame, and anger, whereas emotions associated with PTSD are fear, hopelessness, and horror (Shay 2012).

One can see how moral injuries and PTSD can be linked. Moral injuries also encompass feeling conflicted about the acts in which one participated or witnessed (Shay 2012). Witnessing and engaging in acts of war will likely create moral conflict. War is not a normal everyday occurrence in our country. The realities of war are traumatic and not easily forgotten. Currently, mental health providers are beginning