Role of Morality in the Experience of Guilt and Shame Within the Armed Forces

Act a Psychiatrica Scandinavica

Review Role of morality in the experience of guilt and shame within the armed forces

Nazarov A, Jetly R, McNeely H, Kiang M, Lanius R, McKinnon MC. A. Nazarov1:2, R. Jetly3-4,. Role of morality in the experience of guilt and shame within the armed H. McNeely1'5, M. Kia'ng1-8-7,. forces. R. Lanius8; M. C. McKmnon1-2-9

Department of Psychiatry and Behavioral Objective: Despite advances in our understanding of mental health Neurosciences, McMaster University, Hamilton, ON, issues among military forces, a large proportion of military personnel 2Mood Disorders Program, St. Joseph's Healthcare continue to exhibit deployment-related psychological issues. Recent Hamilton, Hamilton, ON, Department of National work has identified symptoms of guilt and shame related to moral Defence, Government of Canada, Ottawa, ON, injury as contributing significantly to combat-related mental health ''Department of Psychiatry, University of Ottawa, issues. This systematic scoping review explores the association between Ottawa, ON, 'Clinical Neuropsychology Sen/ice, St. morality and symptoms of guilt and shame within military forces. Joseph's Healthcare Hamilton, Hamilton, ON, Method: A search of the literature pertaining to guilt, shame and Department of Psychiaby, University of Toronto, Toronto, ON, Centre for Addiction and Mental Health, morality within military samples was conducted. Toronto, ON , Department of Psychiatry, University of Results: Nineteen articles were selected for review. There is strong Western Ontario, London. ON and Homewood evidence linking exposure to and the perceived perpetration of moral Research Institute, Guelph, ON, Canada transgressions with experiences of guilt and shame. Critically, symptoms of guilt and shame were related to adverse mental health outcomes, particularly the onset ofpost-traumatic stress disorder (PTSD). No studies have explored moral judgment in conjunction with assessments of guilt or moral injury. Key words: post-traumatic stress disorder; military Conclusion: These findings have important implications for the personnel; morality; guilt; shame; moral injury prevention and treatment of PTSD-related symptoms in military Margaret McKinnon, St. Joseph's Healthcare Hamilton, samples. By measuring moral judgment prior to deployment, it may be 100 West 5th Street, Box 585, Hamilton, ON, Canada possible to predict the likelihood of incurring moral injuries and the L8N 3K7. E-mail: [email protected] development of associated symptoms. Early intervention programmes aimed at ameliorating guilt and shame are required to prevent the long- term development of deployment-related psychological distress. Accepted for publication Februaiy 3, 2015

Summations

• The increased number of veterans and active military personnel seeking mental health services points towards an imminent need for an enhanced understanding of how military operations affect the psychological health of army personnel during training, active duty, postdeployment and after release. • There is accumulating evidence suggesting a link between the perceived transgression of moral standards, symptoms of guilt and shame, suicidal ideation and PTSD within military samples. • Recent research surroundmg the concept of moral Injury suggests that experiences of guilt and shame may represent the pathological core of many combat-related FTSD cases.

Considerations

• To date, leading treatment interventions for PTSD have centred predominantly on fear-based symptoms; treatment interventions that target symptoms of guilt and shame in military populations are urgently required. • Early intervention programmes targeting personnel that endorse postdeployment moral injuries may reduce the development of guflt-based PTSD. • Assessment of predeployment styles of moral judgment may predict the likelihood of perceived moral injury and of experiencing symptoms of guilt and shame and therefore the risk of developing combat- related PTSD. Military mental health and morality

deployed to combat-heavy zones increased PTSD Introduction rates to 25% (25). The cumulative risk of devel- The United States (US) Armed Forces and the oping deployment-related PTSD plateaued at Canadian Forces (CF) collectively employ over approximately 6 years following return home 2 400 000 personnel (2 344 000 US; 100 000 CF), from first deployment. The authors of this study, representing 1.5% and 0.5% of the countries' however, suggest that these rates may be underes- total labour forces respectively (1). As of 2013, timated, considering the mental health informa- there are 1 520 100 US and 60 000 CF active per- tion of the sample was available only when sonnel, with units deployed across 150 countries diagnosis was made by CF mental health services (1). With an increase in CF and US veterans seek- and only over the course of a median follow-up ing mental health services (2-4), Canada's Depart- period of 3.7 years. Interestingly, these findings ment of National Defense (DND) and the US parallel reports from the DoD in the United Department of Defense (DoD) have placed States, where the estimated rate ofPTSE)' is 11% increased emphasis on ensuring the mental health among US veterans of the war in Afghanistan of miUtary personnel. This emphasis is evident - (10, 26). Similar to the Canadian experience, rates through the introduction of: more streamlined of PTSD in US veterans who served in what has access to care (5), mental health surveys (6), and been described as heavier combat, particularly in educational programs for personnel and their the Vietnam War, Iraq War and Gulf War, have families geared towards raising mental health been estimated at 30% (27), 20% (26) and 10% awareness (7, 8) and training to cope with stres- (28) respectively. This is in line with reports sug- sors (7, 9). Despite increased efforts to dampen gesting a linear association between combat expo- the residual effects of military operations on the sure and PTSD symptomatology (29). Although psychological health of personnel, operational it is difficult to compare PTSD rates between stress injuries (OSI; persistent psychological diffi- civilian and military samples, according to culties resulting from military duties) are still pre- research conducted prior to the war in Afghani- valent. Post-traumatic stress disorder (PTSD) stan, it is estimated that lifetime prevalence of accounts for the largest proportion of OSI PTSD in Canada is at least two times greater for encountered in the CF (2) and remains one of the soldiers involved in combat than for the general most common disorders seen after deployment in population (30, 31). US personnel (10). In addition to classical symp- Critically, in the United States, veterans com- toms associated with PTSD (e.g. nightmares, prised 22% of all nationwide suicides in 2012 trauma avoidance (11)), recent work indicates that (32). Given that 60% of aU veteran committing combat personnel diagnosed with PTSD also suicide were 50 years of age or older, a large pro- show marked disruptions in emotion regulation portion of the veteran sample represents Vietnam (12, 13), autobiographical memory (14), attention or Korean War veterans, and therefore may not (15), theory of mind (16) and interpersonal func- be indicative of mental health issues faced by cur- doning (17-20). Furthermore, the presence of rent military personnel. As of 2012, however, sui- guilt and shame frequently reported by military cide (349 deaths; 915 attempts) has overtaken personnel (21-23) may interact with these combat operations (311 deaths) as the most com- domains and further exacerbate the alterations mon cause of death in personnel currently serving (24) (e.g. impede relationships through isolation in the US military (33), with ahnost 70% of all and self-deprecation, distort autobiographical currently serving US military suicides involving memory narrative). Critically, these disruptions personnel 29 years old or younger (34). Since the are present despite rigorous mental health screen- onset of the war in Afghanistan and Iraq, the US ing during the selection process, and the presump- military has seen a 100% increase in number of tive selection of personnel that represent a more suicides within active duty personnel (35). Over resiUent subset of the population. the last decade, VAC saw a 600% increase in the A recent study of 2000 CP personnel deployed number of veterans seeking VAC services due to to Afghanistan (2001-2008) indicates that within OSI (from 2000 to 14 500)(36), with over 60% of 4 years of returning home from the combat the- CF personnel se&king VAC mental health services atre, approximately 14% were diagnosed with a after deployment (25). These findings signify an deployment-related mental disorder, with PTSD imminent need for a comprehensive understand- being the most common diagnosis at 8% (25), fol- ing of how military operations affect the psychp- lowed closely by major depressive disorder logical health of army personnel during training, (MDD) at 6%. Within this sample, being active duty, postdeployment and after release. Nazarov et al.

be most relevant to psychopathology, including Guilt and shame depression and PTSD. Numerous theories postu- A series of studies indicate that experiences of guilt late that to experience guilt and shame one and shame are reported widely in individuals with requires a sense of social comparison and the abil- PTSD (21-23) and that both guilt and shame are ity to interpret others' perspectives (53) (e.g. the- closely linked to suicide and suicidal ideation in ory of mind, an ability known to be altered in military samples (37-39). Notably, symptoms of PTSD (54)). Correspondingly, whereas simple guilt and shame have been cited as the leading emotions (e.g. sadness, happiness, anger, fear) cause for seeking US VA mental health services appear developmentally early in life, experiences (40). Despite a breadth of research on fear-based of guilt and shame arise only at approximately PTSD, research on guilt and shame as a core the age of 3-4 years (55), alongside the emergence symptom (41, 42) of PTSD psychopathology has of theory of mind (56-58) and autobiographical been comparatively scarce. Classically, a diagnosis memory (59). of PTSD assumes that an individual is exposed to Although the terms guilt and shame are fre- a trauma where he/she experiences fear, helpless- quently used synonymously, they represent distinct ness or horror in response to the threat to his/her psychological constructs. One of the primary dis- life or the life of someone else. The work of Her- tinctions between the two concepts is the object of man (42), in addition to more recent theories (21, negative evaluation after a moral transgression; 41), however, has proposed that, in some cases, with guilt, the object of evaluation is the specific PTSD may derive from deep feelings of guilt and/ transgressing behaviour, whereas shame entails an or shame after traumatic events, with symptoms of extrapolation of that behaviour to a global evalua- fear being non-existent or secondary in severity. don and redefinition of the self (60). Accordingly, Although guilt is described in DSM-IV, gener- shame entails the process of self-blame for global ally posited as an associated symptom within personal inadequacies or flaws that are perceived MDD, it is a common experience for victims of as being stable over time and not mendable (60- trauma, including but not limited to sexual 62). The accompanying experiences of worthless- assault, transportation accidents, natural disasters ness, powerlessness and inferiority translate into and after exposure to combat/war. Indeed, DSM- behaviours of avoidance and withdrawal. By con- 5 now acknowledges 'persistent distorted blame of trast, guilt involves an acknowledgement of the self or others for causing the traumatic event or deleterious effect of behaviour on others, an appro- for resulting consequences' among the core symp- priate sense of responsibility and an understanding toms of PTSD, falling within Criterion D: nega- that despite the moral transgression, one is still vir- tive alterations in cognitions and mood. Guilt and tuous, future goals are attainable, and reparation shame are complex cognitive and emotional expe- is possible (63). Here, the experiences of tension, riences (43) that arise when one perceives one's regret and remorse are translated into an behaviour to transgress an internal moral stan- 'approach-and-amend' behaviour. Whereas the dard (44). The extent to which guilt and shame psychological distress in shame involves an inward independently relate to adverse mental health out- focus of distress leading to eventual annihilation of comes has proven difficult to evaluate. Shame the self (64), the distress in guilt is channelled out- proneness is associated with PTSD (45), MDD wardly towards interpersonal reparation (65). (46-48), generalized anxiety disorder (49) and sui- Indeed, whereas individuals experiencing guilt dis- cidal ideation (50). Guilt, however, is associated play enhanced interpersonal sensitivity via with negative psychological outcomes only when increased empathy (66) and theory of mind perfor- it is paired with experiences of shame (51). Indeed, mance (65), shame is associated with decreased a recent meta-analysis by Kim et al. (52) found empathy and theory of mind (65) and reduced that whereas guilt is not related to MDD symp- interaction with others (67). Importantly, out- toms when controlling for shame, shame is signifi- comes differ significantly between guilt and shame; cantly associated with MDD symptoms when shame yields self-condemnation, while guilt creates controlling for guilt. Problematically, in the con- an opportunity for self-forgiveness. text of the DSM, the term guilt is captured in a To experience guilt or shame, one must perceive single construct—as a maladaptive, inappropriate one's behaviour as diverging from the moral values sense of responsibility. In the meta-analysis by and standards with which one identifies. In a land- Kim et al. (52), shame was indistinguishable from mark review by Litz et al. (21) of psychological maladaptive guilt (e.g. guilt experienced in the injuries among war veterans, a moral injury was aftermath of uncontrollable negative events), sug- identified as 'any personal action/inaction that gesting that these two interrelated concepts may transgresses this subjective moral standard'. A Military mental health and morality moral injury may occur not only while being the symptoms), it is critical to identify how these fac- perpetrator of the transgressing behaviour, but tors interact. also when: one, bearing witness to it; two, failing to prevent it; or three, experiencing certain emo- Aims of the study tions after learning of transgressing behaviours, with the emotions, upon reflection, being consid- In this review, we explore the literature on the ered subjectively amoral. It has been classically association between morality (moral judgment or observed that a traumatic memory may facilitate exposure to moral transgressors) and the experi- the onset offear-based PTSD. A moral injury may ence of guilt and shame within the military. A sec- also act as, or in lieu of, a traumatic memory, cre- ondary aim was to explore the relation of morality, ating a similar symptom profile (68). Specifically, guilt and shame to the development of adverse experiences of shame mirror the re-experiencing mental health outcomes among military members, and avoidance/emotional numbing symptom clus- including PTSD. ters of PTSD (68). Persistent re-experiencing of moral violations is considered aversive because it Material and methods weakens self-esteem, reinforces feelings of worth- lessness and in turn, leads to increased self-con- To obtain relevant literature, four internet data- demnation and withdrawal (21). Considering the bases (PsycINFO, EMBASE, MEDLINE and large overlap between guilt, shame and PTSD CINAHL) were searched for articles published within the military, the experience of guilt and between January 1900 and June 2014. To be shame may be the fundamental pathological core included in this review, articles must have explored of most combat-related PTSD cases (21, 38, 64). three research domains: morality, guilt/shame and Moral injuries are considered to be much more military (see Table 1 for search terms). To ensure prevalent in today's military, due primarily to the our search strategy was comprehensive, the initial increased unconventionality of several domains of search results contained articles that explored at today's military operations that go against sche- least two of the three domains. We placed no other matic beliefs about warfare (see Litz et al. (21) for restrictions on the initial search. Articles resulting a comprehensive review). Specifically, increased from the search were independently screened by urban warfare and unmarked enemy combatants two raters. In addition, the references of included pose a greater risk to not only military personnel articles were searched for studies not captured by but also increases the risk of harm being inflicted on civilians. Despite military training geared Table 1. Domains and associated search terms investigated in the scoping review towards preparing soldiers for a multitude of situa- Domain tions expected during combat operations, a study of US soldiers serving in Iraq/Afghanistan Guilt/Shame Morality Military revealed that up to 30% faced morally ambiguous Guilt Morality Military situations where they were unsure of how to prop- Shama Morals or moral Army erly react (69). Additionally, in a survey of a simi- Humiliation Moral development Service member or ashamed or Arm* force lar sample of US military personnel, over 20% embarrass* or Military personnel reported being responsible for a non-insurgent's Disgrace* or Veteran death (26). Equally concerning is the large propor- dishono* or Military schools tion of suicides by military personnel that never forgiveness or Military deployment condemn* Military attrition experience combat. For example, a study of suicide Enlisted militaiy personnel within the US Air Force showed that only 25% of Military veterans personnel that committed suicide had ever been Military medical personnel deployed, with only 7% seeing combat (34). It is Military duty status Military psychology possible that military operations within non- Militaiy training deployed personnel may also result in exposure to Volunteer military personnel moral injuries, albeit more subtly. Militaiy psychologists Given that the moral integrity (and at times, dis- Military enlistment Military recruitment engagement) of military personnel is central to a Militaiy families functional military organization, recent awareness War of the potential impact of moral injuries and the Military sen/ices high incidence of psychological distress within the where appropriate, search terms were mapped to keyword headings of each data- military personnel that is comorbid with the base and had its term exploded. experience of moral emotions (guilt and shame ^search was conducted on any combination of characters proceeding the keyword. Nazarov et al. the initial search tenns. The search terms and strat- Table 2 for study characteristics and Table 3 for a egy were confirmed by a health sciences librarian. summary of the results of included articles. Inclusion criteria during title and abstract Correlations between exposure to and the per- screen: ceived perpetration of atrocities and the onset of i) Assessed moral judgment or explored moral guilt symptoms in military personnel have been transgressions. widely reported (40, 71-79). This relation holds ii) Explored experiences of guilt and shame. even when controlling for combat exposure (1, 75, iii) Studied a military sample. 76, 79; see Table 3). In studies that reported this association, the majority of study samples were Inclusion criteria during full-text screen: comprised of primarily Vietnam War veterans i) Text available in full. (sample size mean = 775, SD = 694), although two ii) Primary, peer-reviewed research (no disserta- studies confirmed this relation in Ugandan former tions). child soldiers (77) and in Operation Enduring iii) Written in English. Freedom/Operation Iraqi Freedom (OEF/OIF) iv) Confirmation of focus on the three domains. (78). Tools used to assess guilt in the study samples varied greatly and ranged from validated guilt/ shame scales to dichotomously coded items derived Results from open-ended interviews. In no instance was A total of 6325 references were screened with 19 morality assessed globally (via moral reasoning or articles being selected for review (see Fig. 1 for the judgment) nor with validated scales and instead systematic review screening process). Inter-rater typically involved identifying whether the respon- reliability was high (title and abstract screen: 0.96; dent was exposed to morally injurious events. full-text screen: 0.94), as assessed by Gwet's AC1/2 Combat exposure was assessed primarily by the inter-rater reliability coefi&cient (70). Please refer to Combat Exposure Scale (80). Notably, these

Search results (n = 6325)

Duplicates excluded (n = 1475) ^

Retrieved for title and abstract screen (n = 4850)

Excluded after title and abstract screen ^ (/) =4694)

Retrieved for full-text screen (/7=156)

Retrieved from references (n = 9)

Inclusion criteria filtering (n = 146) - Primary, peer-reviewed articles only - Studied a military sample - Assessed measures of guilt/shame - Assessed morality (moral Judgment or exposure to moral transgressions)

Selected for review (/»=19) Fig. 1. Flow diagram of systematic article selection. Table 2. Study parameters of reviewed articles

Combat exposure Theatre of Guilt/Shame Author (year), County Sample groups PTSD assessed Sample size assessed operations assessments Morality assessments Moral transgression assessments

Laufer(1984),USA(71) Veterans Stress Scale (111) 350 Combat Scale Vietnam War Psychiatric Epidemiological Psychiatric Epidemiological Exposure to Abusive (non-validated) (71) Research Interview (112) Research Inten/iew Violence (Interview - (feelings of guilt subscale) (112) (feelings of non-validated)(71) demoralization subscale) Glover (1990), USA (93) Veterans DSM-111 diagnosis 339 Vietnam War VREQ (93) VREQ(93) Yehuda(1992),USA(73) Veterans SCID(DSM-IH-R|(H3); 40 CES (80) Vietnam War Not explicitly reported - The Atrocity Scale (Brett & Laufer, M-PTSD (92); Rgley potentially HAM-D unpublished) Scale for Combat PTSD (114) Guilt Items (Figley & Stretch. unpublished) Fontana(1992),USA(72) Veterans SCID (DSM-III-R) (113) 1709 Revised Combat Vietnam War AGENT cluster; AGENT cluster (Guilt sx due to Scale (115); FAILURE cluster being the agent of killing) War Stress (guilt sx over failing to measured according to convention Interview (116) fulfil duties/save the used by Laufer et al. (117) wounded, etc.) Henning(1997),USA(74) Veterans CAPS(H8);M-PTSD(92) 40 Revised Combat Vietnam War The Guilt Inventory (119); Combat Guilt Scale (74) (created Scale (80) (85%); WWII (5%); CGS (74) (created for for present study. Subscales: survival Korea (5%); present study) guilt, guilt about acts of commission, Gulf War (5%) guilt about acts of omission, guilt about thoughts/feelings) Kubany(1997).USA(81) Veterans M-PTSD(92);PCL(120) 106 CES(121) Vietnam War Harder Personal Feelings STRGS-WZ(81) Questionnaire (122); The Guilt Inventory (H9);TRGI(123) Beckham(1998),USA(75) Veterans M-PTSD(92);CAPS(118); 151 CESI121) Vietnam War TRGI (123) Vietnam Era Stress Inventoiy Davidson Trauma Scale (125) (Atrocities Exposure subscale) forPTSDim) Fontana (2004), USA (40) Veterans M-PTSD (92) 1385 No objective Vietnam War (95%); Laufer-Parsons Two questions querying Indicated whether 11 experiences measure - distressing WWII (5%) Built Inventory (126) changes in religious were distressing, based on structured experiences only faith (FAITH cluster) interviews (AGENT cluster-killing (see moral others, excitement from killing others, § transgression column) participating in atrocities) I(S3 Witvliet(2004),USA(87) Veterans CAPS(118);M-PTSD(92); 213 Forgiveness of Others The Brief RCOPE (128) ^ CES(121) t~< Davidson Trauma Scale and Forgiveness of forPTSD(124) Self Scales (127) I Man<(2008),USA(90) Veterans SCID (DSM-III-R) (113); 1081 CES (121); War Stress Vietnam War Items from Laufer-Parsons Items from Laufer-Parsons g. &3 M-PTSD (92); PTSD InteiviewlHB) Inventory (115) Inventory (115) KeaneScale(91) u" Klasen (2010), Germany (77) Former Child MINI-KID (129) 330 CSTQI130) Uganda Guilt Cognitions Scale The Brief RCOPE (128) CSTQ (130) (Perpetrator Subscale) sa Soldiers oftheTRGI(123) 3- » Man 12010), USA (76) Veterans SCID (DSM-III-R) (113) 1323 CESI121) Vietnam War Laufer-Parsons Inventoiy (115) One item from the War B Stress Inventory (116) &-

(flI {K M N ta§ re

Table 2. (Continued)

Combat exposure Theatre of Guilt/Shame Author (year), Countiy Sample groups PTSD assessed Sample size assessed operations assessments Morality assessments Moral transgression assessments

Berg (2011), USA (82) Veterans Watson PTSD Interview 94 Vietnam War Berg Spiritual Injuiy Scale* Spiritual Profile Berg Spiritual Injury Scale* (131) (non-validated) Assessment (132); (non-validated) Intrinsic/Extrinsic Religious Motivation Scale (133) Ogden(2011),USA(83) Veterans PCL(120) no CESI121) OEF/OIF Religious Comfort and Religious Comfort and Strain Scale (134) Strain Scale (134); (religious guilt subscale) The Brief RCOPE (128); PTGI (135) Gray (2012), USA (84) Active Duty PCL-M(120) 44 OEF/OIF PTCI (136) Used sx of MOD as a proxy for distress result from traumatic loss and moral injury Stein (2012), USA (78) Active Duty PSS-1 (137) 122 OEF/OIF TRGI (123) (Validation of Moral Injury Categories for war-zone exposure) Nash (2013), USA |85) Active Duty PCLI120) 1039 CES(121) OEF/OIF MIES (85) MIES (85) Vargas (2013), USA (86) Veterans None (NWRS average: 300 Vietnam and 'Self-deprecation' cluster 'Spiritual/Existential Open-ended inten/iew probing 31% lifetime PTSD; other areas from open-ended Issues' cluster from moral injuries (86) 15% current PTSD) served between inten/iew probing open-ended interview 1964 and 1975 moral injuries probing moral injuries Cumer(20U),USA(79) Veterans M-PTSD (92); Diagnostic 1203 Traditional combat Vietnam War 3 dichotomous guilt Four-item measure to assess Inteiview Schedule (138) exposure scale (139) questions during NWRS atrocity exposure

CAPS, Clinician-Administered PTSD Scale; CES, Combat Exposure Scale; CGS, Combat Guilt Scale; CSTQ, Child Soldiers Trauma Questionnaire; DSM, Diagnostic and Statistical Manual of Mental Disorders; HAM-D, Hamilton Rating for Depression; M-PTSD, Mississippi Scale for Combat-Related PTSD; MDD, Major Depressive Disorder; MIES, Moral Injury Evaluation Scale; MINI-KID, Mini International Neuropsychiatric Interview for Children and Adolescents; NVVRS, National Vietnam Veter- ans Readjustment Study; OEF/OIF. Operation 'Enduring Freedom and Operation Iraqi Freedom; PCL, PTSD Checklist; PSS-1, Post-traumatic Symptom Scale, Interview Version; PTCI, Post-traumatic Cognitions Inventory: PTGI, Post-traumatic Growth Inventory; PTSD, Post-traumatic Stress Disorder: SCID, Structured Clinical Inten/iew for DSM Disorders; STRGS-WZ, sources of trauma-related guilt sun/ey-war-zone version; sx, symptoms; TRGI, Trauma-Related Guilt Inventoiv; VREQ, Vietnam Related Experiences Questionnaire. •Found on www.spiritualassessment.com/sis.pdf Military mental health and morality

Table 3. Summary of results from reviewed studies.

Author (Year), Country Results* Limitations laufer (1984), USA (71 ) Caucasian veterans: participation in violence was associated with lower levels of Retrospective feelings of demoralization (6 = -7.5, P < 0.05) and guilt (A = -11.1, P < 0.05) vs. Non-validated inten/iew was used to assess those who did not participate in violence exposure to abusive violence African American veterans: participation in violence was associated with higher levels of feelings of demoralization (A = 11.4, P< 0.05) and guilt (A = 11.5, P < 0.05) vs. those who did not participate in violence Stover (1990), USA (93) Factor analysis of the VREQ items showed that both types of guilt (survival guilt and Combat exposure was not assessed guilt related to acts of abusive violence) wera loaded onto the same factor (1. = 4.6). Retrospective Participants in atrocities may be exposed to a greater number of combat stressors No control group and therefore exposed to both types of traumatic events. Yehuda (1992), USA (73) Strong correlation between exposure to atrocities and HAM-0 scores (r == 0.46, Small sample siza P < 0.05). No associations between combat exposure and HAM-D scores (r = 0.10, P > 0.05). Retrospective Increased exposure to atrocities [r = 0.70, P < 0.05), but not exposure to combat No control group (r = 0.07, P > 0.05), was strongly associated with PTSD sx Associations with HAM-D guilt items were not explicitly reported Non-validated measure of moral transgression exposure Fontana (1992), USA (72) Participation in atrocities was related to increased sx of guilt (i = 0.54, P < 0.0001) Clinician-based measure of exposure to traumas Guilt sx over participation and failura to prevent atrocities was related to an increased Retrospective (up to 20 years) risk of suicide (& = 0.09, P < 0.01: 6 = 0.11, P< 0.0001), more so than to a diagnosis Treatment-seeking only of PTSD [b = 0.07, P < 0.05; ft = 0.08 P < 0.001) Henning(1997),USA(74) Most frequently endorsed items on the CGS related to acts of commission and omission, Small sample size whereas items reflecting suroival guilt, guilt about one's thoughts and feelings during No control group combat, and shame were less frequently reported. Retrospective Increased guilt on the CGS was related to overall PTSD severity (M-PTSD) (r = 0.43, Did not separately analyse P < 0.001) and the re-experiencing [r = 0.46, P < 0.01) and avoidance (r = 0.45, different sources of guilt P < 0.01) subscates of the CAPS. Dichotomous format for guilt items Kubany(1997),USA(81) Most common sources of guilt on the STRGS-WZ did not include guilt due to perpetration Collection of studies developing and validating or exposure to moral transgressions. Inconsistent with popular view that perpetration of the STRGS-WZ scale atrocities is most common source of Vietnam-related guilt Retrospective Beckham(1998),USA(75) Controlling for combat exposure, PTSD (A = 0.54, /? = 0.14, P< 0.05) and guilt sx Retrospective [b = 0.04, /? = 0.13, P< 0.05) were highly associated with Non-validated assessment of exposure and/or perpetration of atrocities perpatration/exposure to atrocities No control group Fontana(2004),USA(40) Guilt sx mediated the association between perpetrations of atrocities and reduced Retrospective comfort derived from religious faith after seivice (direct b: -0.08; indirect: (0.34JI-0.11)) interview-based assessment of traumas Guilt sx jfc = 0.09) and weakened religious faith [tj = -0.08) were strongest predictors No control group for increased use of VA mental health services. Witvliet(2004),USA(87) Negative religious coping and unforgiving of self was related to increased PTSD (M-PTSD) Retrospective !6 = 0.25, P < 0.001; 6 = 0.19, P< 0.01) and depression No control group [b = 0.29, P < 0.001; b = 0.22, P < 0.001) sx Moral injury and general moral reasoning was not assessed Marx (2008), USA (90) Statistical prediction instrument (containing guilt items) identified the presence of FTSD Retrospective more accurately (sensitivity = 0.98, specificity: 0.43) than the PTSD Keane Scale Development and validation study (sensitivity = 0.98, specificity: 0.33) and almost as accurate as M-FTSD Scale (sensitivity = 0.99, specificity: 0.54). Klasen (2010), Germany (77) Resilient child soldiers endorsed less perpetration of moral transgressions vs. child Retrospective soldiers with PTSD (M = 2.87 vs. M = 3.55, P = 0.005) Unique sample - not generalizable to common Severity of perpatration of moral transgressions and exposure to atrocities were military settings significantly associated with guilt sx (r = 0.27, P < 0.001; r = 0.20, P < 0.001), Psychopathology may be also related to PTSD sx (r = 0.24, P < 0.001; f = 0.28, P < 0.001 ), depression sx (r = 0.22, trauma related to family separation P < 0.001; r = 0.32, P < 0.001) and lowered perception of spiritual support (r - 0.18, P< 0.01; r= 0.12, P< 0.05) Marx (2010), USA (76) Combat-related guilt indirectly mediated the relation between exposure to abusive Mediation analysis on cross-sectional data violenca and PTSD (indirect effect: 0.24) and MDD (indirect effect: 0.16) diagnoses Retrospective Relation between participation in abusive violence and PTSD (indirect effect: 0.21) Small sample size and MDD (indirect effect: 0.12) diagnoses was fully mediated by combat-related guilt Berg (2011), USA (82) Guilt sx, lack of meaning and religious doubt (subscales from the Spiritual Injury Did not differentiate between trauma aetiology Scale) were strongly correlated with depression {t = 4.35, P < 0.001; t = 8.23, Moral injury and general moral reasoning P < 0.001; t = 2.92, p = 0.004) and PTSD {t = 4.05, P <• 0.001; t = 5.91, was not assessed P< 0.001; t= 2.63, ,'=0.01) sx Ogden (2011), USA (83) PTSD sxwere related to alienation from God (r» 0.36, P< 0.001) and religious Moral injuiy and general moral reasoning fear and guilt (f = 0.25, P < 0.001) was not assessed Religious factors predicted 14% of variance in FTSD sx Only generalizable to Christian faith treatment-seeking sample only

11 Nazarov et al.

Table 3. (Continued)

Author (Year), Country Results* Limitations

Gray (2012), USA (84) Despite improvements in FTSD sx, veterans did not demonstrate significant reductions Small sample size in self-blame severity after adaptive disclosure treatment (pretest M = 2.51 vs. posttest M= 2.31, P= 0.14) Stein (2012), USA (78) Moral injury by self was associated with re-experiencing symptoms (b = 0.28, Review of non-validated structured P = 0.015) and TR6I Hindsight-Bias/Responsibility |fi = 0.39, P = 0.003) and clinical interviews Wrongdoing (6 = 0.26, P= 0.043) subscales. Retrospective treatment-seeking sample only Event coding was ambiguous Nash (2013), USA (85) ^ Perceived moral injury was not associated with combat exposure (r = 0.08) Development and validation study Perceived moral injury was associated with increased depression sx [r = 0.40), Retrospective anxiety sx (/• = 0.28), negative affectivity (/• = 0.29), PTSD sx (r = 0.28) and lower social support (/• = -0.29) (Interpersonal Support Evaluation List) Vargas (2013), USA (86) Based on an interview exploring symptoms experienced in the aftermath of moral No mental health outcomes injury, guilt and shame (Self-Deprecation theme) were found to be within the archival data moral injury construct; however, frequency of this theme is lower than of feelings Raters were not blind of loss of trust and existential/spiritual problems. Cumer (2014), USA (79) Severity of guilt sx was associated with degree of exposure to atrocities (SEM Lack of validated measures for guilt and estimate = 0.19. P < 0.001) (controlling for combat exposure) atrocity exposure Retrospective

CGS, Combat Guilt Scale; HAM-D, Hamilton Rating for Depression; M-PTSD, Mississippi Scale for Combat-Related FTSD; MOD, Major Deprsssive Disorder; PTSD, Post-traumatic Stress Disorder; STR6S-WZ, sources of trauma-related guilt survey-war-zone version; sx, symptoms; TRGI, Trauma-Related Guilt Inventory; VREQ, Vietnam Related Experiences Questionnaire. •Positive results and associations reported in this table were statistically significant. studies have several important limitations, point- Several studies (while also limited by retrospec- ing towards the need for additional study: all tive self-report) have differentiated further the involved retrospective self-report and were thus impact of being either an observer or an agent of vulnerable to memory decay and systematic moral transgressions, finding that guilt is experi- reporting biases (e.g. halo effect). Social desirabil- enced by military members after both perpetration ity factors may contribute further to underreport- (40, 71, 72, 76, 77) and observation (73, 76, 77, 79) ing of morally transgressive actions perceived as of moral transgressions. Two studies involving unacceptable to others. In addition, sample sizes restricted samples of Vietnam veterans, however, were relatively small in the majority of studies sur- reported null findings where the perpetration of veyed (73, 74,78,81-84) and, as noted, relied upon atrocities was not identified as a common source of non-validated measures to assess morality, guilt guilt (81, 86); critically, however, the Vargas et al. and shame. Moreover, civilian control groups were study relied upon archival data, which may have not included to assess the relation between morally limited significantly the scope of participant injurious acts (e.g. denying a patient medical care) responses available for analysis. and experiences of guilt and shame in non-military Among the articles selected for review, several samples. reported associations between guilt (with or with- In one key validation study of the Moral Injury out exposure to perceived moral transgressions) Evaluation Scale (MIES), also relying upon retro- and symptoms of PTSD (74, 75, 82, 87) and of spective self-report, Nash et al. (85) provided addi- MDD (82, 87) in military members, including the tional evidence implicating moral transgressions as onset of re-experiencing (74, 75) and avoidance a source of psychological distress experienced after symptoms (74). These findings contribute to the deployment. Although Nash et al. (85) did not growing body of literature relating experiences of measure specifically symptoms of guilt and shame, guilt with poor mental health outcomes among the authors did examine experiences of moral military members (37, 38, 52, 64, 88, 89); notably, injury, which include feelings of guilt and shame these studies did not assess independently experi- experienced in the aftermath of moral transgres- ences of guilt and of shame, and cross-contamina- sions (86). Specifically, Nash found that increased tion of these concepts is probable across measures. perception of moral injuries was related to PTSD Direct exposure to and/or perpetration of moral and MDD symptomatology and a lower index of transgressions has also been related to several social support. Critically, MIES scores were not mental health outcomes such as severity of PTSD related to the degree of combat exposure, support- (71, 73, 75, 77, 78, 83, 85), severity of MDD (73, ing the notion that moral injuries provide an 77, 85) and suicidal ideation (72). Critically, in one independent source of psychological distress. study, formal mediation analysis revealed that

12 Military mental health and morality combat-related guilt mediated the relation between mental health outcomes was also examined. Our exposure to and participation in retrospectively review of the extant literature strongly suggests reported perceived atrocities and subsequent diag- that exposure to and perceived perpetradon of noses ofPTSD and MDD (76). The results of this morally transgressive acts that result in the incur- study suggest that the onset of symptoms of guilt rence of moral injuries during military service are and shame following either participation in or associated with the emergence of symptoms of observation of perceived atrocities contributes sig- guilt and shame. The emergence of symptoms of nificantly to the onset of PTSD and of MDD in guilt and shame following moral injury appears to military samples. Interestingly, a statistical predic- mediate the onset of psychopathology, including tion instrument developed by Marx and colleagues PTSD and MDD, among military members and (90) containing items relating to guilt and moral may increase risk of subsequent suicide. Critically, transgressions predicted a diagnosis ofPTSD more this association holds regardless of the degree of accurately than did the PTSD Keane Scale (91) combat exposure. To our knowledge, however, no and almost as accurately as the Mississippi PTSD studies have directly explored the association Scale (92). between validated measures of global moral rea- Several studies have explored further the con- soning/judgment and the onset of symptoms of cept of morality via changes in religious function- guilt within military personnel. This effort will ing among military members. Fontana et al. (40) have important implications for understanding found that in personnel who completed military how moral injury, guilt, and shame interact to service, guilt symptoms mediated the association influence mental health outcomes among military between retrospective self-report ofperpetration of personnel. atrocities and reduced comfort derived from reli- The study of morality is particularly pertinent to gious faith. Furthermore, negative religious coping the military as military service exposes individuals and alienation from God were related to increased to unique, morally salient situations. The army is a PTSD (83, 87) and MDD (87) symptomatology. tool of war. Participating in the military generally Ogden et al. (83) found that religious factors pre- involves an assumption that one creates a better dieted 14% of the variance in PTSD symptomatol- world, for the nation or humanity, albeit by the ogy in a group of veterans who experienced use of force (also assuming that all other non-vio- combat in OEF/OIF; moral injury was not lent means have failed). As the use of force assessed directly in these studies. Studies relating involves the violation of individual rights, the con- to other topics of morality include the work of cept of using violence as an instrument of peace Laufer et al. (71), who found that participation in parallels the idea of sacrifice for greater good. violence was associated with higher demoralization Moral conflict generally arises during these types in African American Vietnam veterans and lower of situations, where one's innate feelings of what is demoralizadon in Caucasian Vietnam veterans. right and wrong (deontological thought) are pitted Moreover, among veterans who participated in against a more cognitive, calculated, objectively perceived abusive violence, whereas Caucasian vet- advantageous outcome (utilitarianism). Converg- erans described feeling indifference to the fate of ing with neuroimaging data (94-97), moral emo- civilians and the maintenance a full war mentality, dons (e.g. guilt and shame) and empathic concern African Americans veterans reported dissonance are generally associated with a more deontological between their current attitude and behaviour in the morality. Nonetheless, morality is dynamic, sub- combat theatre. Finally, despite assessing guilt and jective and open to socio-cognitive influence (98). moral transgressions separately and being included Social psychologists, particularly Bandura (98), in this review, two studies did not go on to explore have coined the term. moral disengagement — the the association between guilt and morality, thus phenomenon when an individual or a group of yielding no interpretable findings for the current individuals disconnect their internal moral code analysis (84, 93). As reviewed, the studies reported from moral action and, ultimately, one's conduct here suffer several significant limitations, summa- is not perceived.-as immoral but is seen as honour- rized on a study-by-study basis in Table 3. able. Generally, diffusion and displacement of responsibility (i.e. through division of labour), euphemistic language (e.g. bombing referred to as Discussion 'clean, surgical strikes', suggesting acts of healing) The primary scope of this review was to explore and dehumanization all attribute to the removal of how morality contributes to the experiences of the self as inflicting direct harm, therefore dampen- guilt and shame within military samples; the ing emotional contagion from otherwise complex relation of guilt, shame and morality to subsequent moral dilemmas (98). We conceptualize moral

13 Nazarov et al.

disengagement as the disengagement of deontolog- of perceived social support has been a robust ical thought, where the value of the moral decision predictor of chronic PTSD (103, 104). Critically, is placed exclusively on the calculated outcome. the perception of forgiveness from others mediates Within a military context, the amplitude of utilitar- self-forgiveness over time (105), pointing further ianism is assumed to be high, with the goodness of towards the vital importance of maintaining social the outcome generally defined by authority and support in populations at risk for PTSD and for meant to be taken at an authoritarian face value. moral injury. In addition, military sexual trauma The military is an organization that generally func- (MST; sexual assault, rape or harassment occur- tions through utilitarian methods, suggesting that, ring during military service) has received increasing over time, military personnel will develop a shift attention in recent years, where approximately towards a more utilitarian moral judgment. This 20% of female and 1% of male VA healthcare idea remains to be explored, however. users report experiencing at least one MST during The studies reviewed have several limitations. As their service, representing almost 100 000 person- with any situation involving feelings of shame, full nel positively screened by the VA in 2008 alone disclosure may be associated with significant hesi- (106); sexual trauma is closely linked to intense tation and fear of judgment by others. Reporting guilt and shame among personnel and represents a observation of or participation in the perpetration key intervention target. Moreover, perpetrators of of acts that transgress moral standards during MST may present with similar patterns of guilt deployment is no exception, suggesting that these and shame, particularly upon return from service types of events may be underreported (73). More- and integration into civilian life. Finally, in the over, self-reports of guilt and shame have been aftermath of moral injury, a proportion of soldiers shown to be moderated by cultural factors (99). As may experience changes in religious faith and diffi- mentioned previously, the interchangeable use of culty finding meaning in their actions postdeploy- terms guilt and shame within the majority of stud- ment; treatment of individuals with combat-related ies limits our ability to explore the independent psychological distress must address the spiritual roles of distinct experiences of guilt and shame. and existential changes involved with such experi- Although the studies reviewed here included sam- ences (40, 77, 83). pies comprised primarily of Caucasian Vietnam Given the high rates ofPTSD within the military War veterans, the increased multiculturalism of and the increasing number of veterans seeking today's Western military may add additional vari- VAC mental health services, there is an urgent ance surrounding the propensity to report guilt need for research that increases the capacity for and/or shame within military personnel. A signifi- the prevention and treatment of combat-related cant proportion of the studies sampled included PTSD. The results of the present review point treatment-seeking veterans tested several years towards strong relations between the incurrence of after combat; non-random sample selection, mem- a moral injury, the subsequent development of ory decay and retrospective reporting add addi- symptoms of guilt and shame and the emergence tional bias to the findings. Finally, the findings of psychopathology, including MDD and PTSD. reported here are correlational and do not provide Although it is not possible to predict who will be direct evidence that moral injuries lead to the onset exposed to morally questionable events during of guilt and related psychopathological symptoms. deployment, it may be possible to predict who is Longitudinal studies are instead urgently required more likely to perceive such events as morally inju- to establish the course of psychopathology stem- rious. By assessing predeployment styles of moral ming from moral injury and attendant guilt and judgment using validated assessment tools (e.g. distress. Defining Issues Test (107), Moral Competence In addition to moral injuries stemming from Test (108)), we may be better able to identify those observed or perceived moral transgressions in the military members most likely to experience moral combat theatre, several other factors may influence injuries, to have resulting symptoms of guilt and moral emotions, moral judgment and psychopa- shame and thereby a greater risk of developing thology as they relate to military service. Specifi- combat-related PTSD and/or MDD. Given that cally, a past history of childhood trauma has been the emergence of guilt and shame (additional tar- associated with combat-related PTSD in soldiers gets of systematic measurement) is dependent on (100), shame-inducing thoughts (48) and shame one's perception of behaviour as diverging from proneness (101). Notably, military personnel are personal moral values and standards, assessing frequently separated from traditional sources of these moral standards prior to deployment may social support, potentially altering the dynamics elucidate how individuals may emotionally and stability of these relationships (102, 103); lack respond to morally ambiguous circumstances in

14 Military mental health and morality

the combat theatre. Members identified as being at address the enduring impact of moral injuries on risk for moral injury may then be targeted by military personnel. preventive and/or early intervention efforts. Pre- emptive screening and removal from service of Acknowledgement individuals at risk for moral injury and associated symptoms of guilt and shame is not warranted, We thank Jasneet Dhaliwal and Alien Tedjo for their assis- where instead it is those individuals with an appro- tance in the preparation of this manuscript. priately high sense of personal responsibility and intolerance for moral transgressions who are Declaration of interest actively sought among military ranks. Interest- None. ingly, a survey conducted with OIF US personnel reported that although 45% of personnel agreed References that non-combatants should be treated with respect, 17% of the sample believed that non- 1. International Institute for Strategic Studies. 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