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An Exploration of Moral Injury As AN EXPLORATION OF MORAL INJURY AS EXPERIENCED BY COMBAT VETERANS A dissertation presented to the faculty of ANTIOCH UNIVERSITY SANTA BARBARA in partial fulfillment of the requirements for the degree of DOCTOR OF PSYCHOLOGY in CLINICAL PSYCHOLOGY by Marjorie M. McCarthy, J.D., M.A. 2016 ProQuest page…. ii AN EXPLORATION OF MORAL INJURY AS EXPERIENCED BY COMBAT VETERANS This dissertation, by Marjorie M. McCarthy, has been approved by the committee members signed below who recommend that it be accepted by the faculty of Antioch University Santa Barbara in partial fulfillment of requirements for the degree of DOCTOR OF PSYCHOLOGY in CLINICAL PSYCHOLOGY Dissertation Committee: ____________________________ Ron Pilato, Psy.D. Dissertation Chair ____________________________ Sharleen O’Brien, Psy.D. Second Faculty ____________________________ CAPT William P. Nash, M.D., MC USN (Ret.) External Expert iii Copyright © 2016 Marjorie M. McCarthy All rights reserved. iv Abstract War-zone stressors among Service members can lead to adverse psychological consequences that fall outside the scope of post-traumatic stress disorder. Combat stressors can also result in moral injury. Moral injury is an emerging psychological construct. One proposed definition of moral injury is the perpetration of, failure to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations. The current study used this proposed definition to conduct a qualitative phenomenological investigation of the lived experience of moral injury among combat Veterans of the wars in Iraq and/or Afghanistan. Eight male combat Veterans who self-identified as having the experience of moral injury as put forth in the proposed definition, were individually interviewed. Qualitative analysis was utilized to uncover themes related to morally injurious events and psychological sequela. The findings revealed support for the proposed definition of moral injury as well as six themes describing morally injurious experiences: shame, guilt, and feeling unforgivable connected to the involvement of children in war; shame, guilt, and anger for taking part in killing others; shame, guilt, anger, and feeling unforgivable when they did not speak- out regarding morally injurious events they were a part of as a group; no longer holding the same religious/spiritual beliefs; a loss of meaning in life after viewing death and a sense that they deserved to be disgraced after the way they handled the human remains of the enemy and witnessing others disgrace human remains of the enemy; and difficulty reconnecting emotionally with loved ones after their morally injurious experiences in combat. The most endorsed theme by the Veterans related to morally injurious experiences with children in war. Results suggest an important area for future research could help to define ways to prepare Service members for encountering child soldiers as well as potential ways to manage witnessing the suffering of children in war. The electronic version of the dissertation is accessible at the Ohiolink ETD center http://www.ohiolink.edu/etd. v Acknowledgements I first want to thank each participant for their willingness to share their experiences with me. For most, it was a difficult and emotional interview and I deeply appreciate your contributions. Only because of each of you was this study possible. I want to thank Mums and Tums for their unending support and love, you also helped make this possible. I relied on the friendship and support of Erin and Gena to push me to the finish line, thank you my friends. Thank you to my dissertation committee for your valuable input and support. Each one of you are remarkable and appreciated more than you could know. Finally, I have to thank my furry companions Lucy, Ricky Martin, Freddy, and Bae Bae who were with me every step of the way. vi Table of Contents Abstract ....................................................................................................................v Acknowledgements ................................................................................................ vi Table of Contents .................................................................................................. vii List of Tables ......................................................................................................... xi Chapter I: Introduction ............................................................................................ 1 Chapter II: Literature Review ............................................................................... 10 The Concept of Moral Injury Throughout History ........................................... 10 Proposed Definitions of Moral Injury ............................................................... 13 Psychological and Behavioral Sequela of Moral Injury ................................... 16 Research to Define Moral Injury ...................................................................... 18 U.S. Troops Are Trained to Kill ....................................................................... 23 Atrocities Exposure and Killing: Perpetration Element of Moral Injury .......... 28 Killing in Combat, Moral Injury, and Suicide. ............................................. 32 Elements of Moral Injury: Failure to Prevent,Witnessing, Learning About Acts ......................................................................................... 35 Assessment Tools ............................................................................................. 36 Treatment Interventions .................................................................................... 39 Chapter III: Methods ............................................................................................. 50 Research Design ................................................................................................50 Procedures .........................................................................................................52 Participants .....................................................................................................52 Recruitment ....................................................................................................52 vii Inclusion/Exclusion Criteria ...........................................................................53 Prescreening ...................................................................................................53 Preliminary Meeting .......................................................................................54 Interview. ...................................................................................................... 55 Treatment of Data ............................................................................................. 57 Informed Consent/Authorization ..................................................................57 Data Recording .............................................................................................58 Transcription. ................................................................................................ 58 Data Analysis ....................................................................................................58 Assume the Reductionist Psychological Perspective .................................... 58 Holistic Review ..............................................................................................59 Defining Meaning Units .................................................................................59 Transform the Implicit into the Explicit in Ways That Are Psychologically Sensitive .........................................................................................................60 Create Structures of Experience .....................................................................61 Methodological Assumptions and Limitations ................................................. 62 Ethical Assurances ............................................................................................ 64 Chapter IV: Results ................................................................................................66 Demographics ....................................................................................................66 Summary of Results ..........................................................................................68 Combined General Constituent Themes .........................................................69 Combined General Constituent Theme 1: Participants Experienced Shame, Guilt and Feeling Unforgivable Connected to the Involvement of Children in War .................................................................................................................72 viii Combined General Constituent Theme 2: Participants Experienced Shame, Guilt, Anger, and Feeling Unforgivable for Taking Part in Killing Others ...77 Combined General Constituent Theme 3: Participants Experienced Shame, Guilt, Anger, and Feeling Unforgivable When They Did Not Speak-Out Regarding Morally Injurious Events They Were a Part of as a Group ..........80 Combined General Constituent Theme 4: Due to What They Experienced in War, Participants No Longer Held the Same Religious/Spiritual Beliefs ......82 Combined General Constituent Theme 5: Participants Experienced a Loss of Meaning in Life After Viewing Death and a Sense That They Deserved to Be Disgraced After the Way They Handled Human Remains of the Enemy and the Way They Saw Others Disgrace Human
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