Tending to Veterans' Moral Injuries

An interview with Dr. Brandon Griffin on caring for veterans.

Posted Oct 20, 2020

Brandon Griffin, used with permission
Source: Brandon Griffin, used with permission

Internal moral conflicts can tear the average person apart, but this is exacerbated for veterans who are responding to high-intensity situations. In this interview, Dr. Brandon J. Griffin shares the findings of his study on student veterans’ experiences with moral distress.

Brandon J. Griffin, Ph.D., is a licensed clinical psychologist and health services researcher at the Central Arkansas Veterans Affairs (VA) Health Care System and Assistant Professor at the University of Arkansas for Medical Sciences. His interests include the development, evaluation, and implementation of interventions designed to promote resilience and well-being among individuals and communities. He primarily works with people who are exposed to highly stressful and traumatic events in the line of duty, including military Veterans and first responders. Dr. Griffin is co-editor of the Handbook of the Psychology of Self-Forgiveness.  

Jamie Aten: How did you first get interested in this topic?

Brandon Griffin: During military service, Veterans sometimes make critical decisions with limited time and information under emotional distress and situational constraints. In doing so, they may have transgressed their personal moral beliefs, even if they followed military-related ethical rules and guidelines. While not everyone exposed to an event that transgressed their beliefs about right-and-wrong will experience lasting problems, some Veterans describe psychological and behavioral, social, and religious or spiritual issues that mental health professionals refer to as a moral injury.

I am interested in moral injury because many people in my generation joined the military with the goal of serving the greater good after the September 11, 2001 attacks. But the chaos of combat can elicit questions about commitment to one’s moral principles, making the return to civilian life very disorienting. For example, Veterans who feel like they perpetrated a moral transgression during their military service may think that they do not deserve good jobs or supportive relationships after returning home. The goal of my research is, therefore, to understand how to best equip Veterans to make sense of impossible situations encountered during service and approach the future with hope and resilience.

JA: What was the focus of your study?

BG: In this study, student Veterans answered questions about their psychological, social, and spiritual well-being. They were also asked about their experiences of moral distress associated with deployment-related events in which they felt (a) troubled by what they witnessed, (b) troubled by what they did, (c) troubled by what they failed to do, (d) betrayed by military leaders, and (e) betrayed by fellow service members.

The coauthors of this article and I were interested in improving understanding of moral injury in student Veterans in particular. A considerable number of Veterans enroll in academic and vocational training programs each year through educational benefits available to Veterans (e.g., Post-9/11 GI Bill), and one innovation within VA care involves tailoring mental health treatments to student Veterans and delivering care in educational settings.

However, little is known about student Veterans’ experiences of moral injury. A better understanding of how moral injury contributes to the educational and occupational functioning among student Veterans will aid in the development of targeted interventions.

JA: What did you discover in your study?

BG: Whereas student Veterans reported some problems (e.g., conflict with others) regardless of whether they were exposed to a perceived transgression by witnessing, perpetrating, or being betrayed, in comparison to those reporting no moral distress, those who felt personally responsible for the event reported greater guilt and lack of purpose, and those who held others responsible for the event reported greater post-traumatic stress. Student Veterans who endorsed feeling betrayed by others and troubled by their own actions reported multiple problems, including post-traumatic stress, interpersonal difficulties, and religious or spiritual struggles.

JA: Is there anything that surprised you in your findings or that you weren't fully expecting?

BG: Despite being at risk for other problematic outcomes, student Veterans might “fall through the cracks” if they have sustained a moral injury but do not also screen positive for a formalized medical or psychiatric diagnosis. This is because moral distress, especially among those who feel personally responsible for a deployment-related event that they think was morally wrong, doesn’t always lead to problems like Post-traumatic Stress Disorder or Major Depressive Disorder.

In fact, experiencing distress in response to something that you think is morally wrong can be a sign of a working moral conscience. A problem can result when culturally sanctioned methods of resolving moral distress are not available. For instance, some Veterans may feel a need to apologize but believe that it is impossible for them to make amends, and they may consequently punish themselves to atone for what happened. Part of therapy designed to facilitate moral repair involves overcoming barriers to reparation that may contribute to prolonged and global negative self-evaluations.

JA: How might readers apply what you found to their lives?

BG: Negative emotions like guilt and shame are stressful, and stress can negatively impact a person’s physical and mental health. Still, it is inevitable that people will sometimes fall short of their moral principles. Practice genuine self-forgiveness by accepting responsibility for your actions alongside accepting yourself as a flawed but valuable person who is capable of growth.

Research has repeatedly shown that people who forgive themselves have lower cardiovascular risk, better immune system functioning, less stress and depression, stronger relationships with others, and more meaningful connections to whatever they believe is sacred (e.g., God, humanity, etc.).

JA: How can readers use what you found to help others?

BG: One of the biggest challenges of moral injury is that when Veterans condemn themselves for something that happened during their military service, they often assume that they will be condemned and rejected by others as well. They may feel like they no longer belong with or that they are a burden on others. For these reasons, it is not hard to see why research shows that moral injury is a risk factor for suicide-related thoughts and behaviors.

If you know a Veteran who struggles with moral injury, encourage them to reach out to VA or other health care organizations. Evidence-based treatments for psychological trauma are widely available, and treatments designed to facilitate recovery from moral injury among Veterans can be found at many VA medical centers. In addition, people in crisis can receive free and confidential support by contacting the National Suicide Prevention Lifeline by phone at 1-800-273-8255 or online.

JA: What are you currently working on that you might like to share about?

BG: Although moral injury has primarily been studied in military Veterans, health care and emergency personnel may also experience difficult ethical challenges in the line of duty. This is especially true during disasters and crises, including the coronavirus pandemic. For example, medical personnel sometimes make difficult decisions about limiting access to potentially lifesaving testing and treatments due to lack of supply. I am currently working with a group of clinicians and researchers across the country to better understand and promote resilience toward difficult ethical situations encountered by essential workers involved with caring for people infected with COVID-19.

Disclaimer: The opinions expressed in this article are Dr. Griffin’s and do not necessarily reflect the official positions of the United States Government, academic affiliates, or funding partners with whom Dr. Griffin collaborates.

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Griffin BJ, Williams CL, Shaler L, Dees RF, Cowden RG, Bryan CJ, Litz B, Purcell N, Burkman K, Maguen S. Profiles of moral distress and associated outcomes among student veterans. Psychol Trauma. 2020 Oct;12(7):669-677. doi: 10.1037/tra0000584. Epub 2020 Apr 30. PMID: 32352806. https://pubmed.ncbi.nlm.nih.gov/32352806/