The link between moral injury and suicide
What's the issue?
The suicide rate for serving and ex-serving defence force personnel is higher compared to the general population in Australia and internationally.1 Often risk factors such as post-traumatic stress disorder (PTSD) are viewed as an explanation as to why defence force personnel die by suicide at higher rates than the general public. Given that suicide cannot be attributed to one single factor, researchers propose that moral injury may have a significant influence on suicide in military populations.
Moral injury is a concept that has been proposed to better understand factors that can contribute to suicide among defence and veteran populations that relates to contradicting personal morals and values. While there are various definitions of moral injury in the literature, most describe it as a form of bio-psycho-social-spiritual distress that arises from a breach or betrayal of one’s moral values and or beliefs.2 Defence Force personnel may be exposed to situations where they are required to make decisions that don’t align with or significantly challenge their morals. Moral injury usually occurs when actions lead to betrayal of personal morals, which can lead defence personnel to question their goodness, and the goodness of the world.3,4 This can lead to negative thoughts and beliefs, and for some may lead to suicidal thoughts and behaviours.
The physical and psychological impacts of moral injury and PTSD are similar. People impacted by moral injury may experience anger, sleep disturbances, and emotional detachment. Unlike PTSD however, people impacted by moral injury can also experience emotions such as self-blame, grief, sorrow, betrayal and existential crisis.5
What was done?
Researchers conducted a systematic review of the literature to examine the experience of moral Injury in a military context and its link to suicidal thoughts and behaviours. The systematic review adhered strictly to a published protocol registered in PROSPERO.
Researchers conducted a review of six data bases (PubMed, Google Scholar, PsycINFO, Scopus, British Medical Journals (BMJ), and ScienceDirect for peer-reviewed literature published between January 2009 to April 2023.
The year 2009 was chosen as this is when a widely accepted definition of moral injury was established.
A number of search terms were used in the review that related to Moral Injury, military and veterans, and suicide.
What was found?
2,214 publications were examined. Eligible studies focused on active or formerly serving military personnel from Australia and countries with similar military organisation (for example UK, Canada, Europe) and included an assessment of moral injury and any links to suicidal behaviour. 12 studies were included in the review.
Review of the literature found that:
- Moral injury caused by situations or events when a Defence Force member acted in a manner that broke their personal moral code were associated with suicidal thoughts, behaviours and attempts.
- Moral injury caused by situations or events when a Defence Force member witnessed others acting in ways that broke their personal moral code were associated with suicidal thoughts, behaviours and attempts, but at lower rates.
- Some studies in the review showed mixed associations or no association between moral injury events perpetrated by others.6
- Experiencing perceived betrayal by oneself showed a 50 per cent higher likelihood of suicide among men, whereas experiencing betrayal through others leading to moral injury is linked to over a 50 per cent higher rate of suicide for women.
- The presence of both PTSD and moral injury significantly increased the risk of experiencing suicidal thoughts and behaviours.
- Moral injury through perceived betrayal by others were found to have significant implications for suicidal behaviour.
Overall, perceived betrayal by oneself had an increased association with suicidal ideation that was driven by feelings of shame.
There was a relationship between moral injury, shame, and suicidal ideation.
Having stronger beliefs, goals, and purpose in life was linked to reduced suicidal ideation for those who experienced perceived moral Injury through betrayal and the actions of others. Having social connections and practising mindfulness may prevent suicidal thoughts and behaviours for moral injury caused through perceived betrayal of others.
The researchers note some important limitations of this study. The research included in the review were all cross sectional, retrospective data sets. This data may not be representative of the whole population and cannot be compared to other populations.
There were insufficient examinations of participants' mental health diagnoses and physical and psychological experiences, and it was difficult to compare between research studies.
Suicide risk between studies was not validated against established measures which brings some uncertainty to the findings.
Finally, most studies used self-reported data which may not provide a true picture of the impacts of moral injury.
Why are the findings important?
Suicide in serving and ex-serving Defence Force personnel cannot be due to PTSD and other commonly known risk factors for suicide. The literature shows that moral injury can play a significant role in suicidal thoughts, behaviours and attempts for defence force personnel.
Further research is encouraged to understand the experiences of military personnel and their emotional, psychological, behavioural, social, and spiritual functioning whilst experiencing moral injury to support a more comprehensive understanding and inform prevention approaches.
Notes
- 1
Australian Institute of Health and Welfare. Serving and ex-serving Australian Defence Force members who have served since 1985: Suicide monitoring 1997 to 2020. AIHW; 2022. Available from: https://www.aihw.gov.au/report...
- 2
Boudreau T. The morally injured. Mass Rev. 2011;52(3/4):746-754. Available from: https://www.jstor.org/stable/23210143
- 3
Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clin Psychol Rev. 2009;29(8):695-706.
- 4
Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2), 182–191.
- 5
Griffin BJ, Purcell N, Burkman K, et al. Moral injury: An integrative review. J Trauma Stress. 2019;32(3):350-362. Avail
- 6
Wisco BE, Marx BP, May CL, et al. Moral injury in US combat veterans: Results from the national health and resilience in veterans study. Depress Anxiety. 2017;34(4):340-347.