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The dominating emphasis of psychological research into moral injury has focused on clinical assessment, diagnosis, and treatment. This article focuses on the particular case of the role of the leader/leadership in moral injury in a military context. To address this objective, a systematic scoping literature review was conducted with the aim of investigating the scope of existing research to identify gaps and encourage future research and interventions. Thematic analysis was used to structure the data in an explorative inductive manner and an attempt was made to integrate the themes identified to gain a more holistic understanding of the subject matter. The results show that a significant portion of the literature views leadership failure or leader betrayal as a potentially morally injurious event (PMIE), a primary cause (predictor) of moral injury. However, a significant number also view leadership as a key factor in the prevention and mitigation of moral injury. Consequently, the lack of empirical evidence focusing on the role of leadership in moral injury must be regarded as problematic and should be given greater emphasis to advance understanding and guide the development of effective, evidence-based interventions.

The aim was to explore the relationship between moral injury symptoms, individual and military potential antecedent variables, and mental health scales. Responses were obtained from 504 Swedish military veterans. Findings showed that moral injury symptoms were modestly related to emotional stability and combat exposure. Moral injury symptoms were moderately strongly related to stress-related physical and psychological symptoms and strongly related to PTSD indication. The results suggest a strong conceptual overlap between moral injury symptoms and PTSD indication. The association between moral injury symptoms and stress-related physical and psychological symptoms was discussed from an intervention perspective. The study also adds to previous research in that the sample had more favorable mental health, when measured by stress-related symptoms and PTSD indication. Possible reasons for this are strict selection criteria and a lower frequency and intensity of combat exposure.

Purpose

This study is a scoping literature review of research into post-traumatic stress disorder (PTSD) and moral injury (MI) in active-duty military personnel and veterans in Ukraine. This study aims to explore the existing research regarding the relationship between PTSD and MI in Ukrainian military personnel to identify the need for future research in a vulnerable social group that is exposed to a high level of conflict.

Design/methodology/approach

This scoping review includes the results of peer-reviewed articles from online databases (PubMed, Science Direct, PsycArticles, Military Database, Sociological Abstract, Psychology Database, PTSD Pubs, Web of Science), which were searched for publications in English, Ukrainian and Russian. The data obtained was organized using Preferred Reporting Items for Systematic Reviews extension for scoping reviews and Meta-Analyses, the Critical Appraisal Skills Programme Qualitative Studies Checklist and Joanna Briggs Institute Critical Appraisal Checklist. Data was analyzed and categorized using an inductive thematic analysis.

Findings

According to the thematic analysis, the following themes were identified in a Ukrainian military context: sources of PTSD, sources of moral injury, symptoms of PTSD, symptoms of moral injury and treating and prevention mechanisms. All studies included in the scoping review (32) report on PTSD and/or MI in military groups in Ukraine. They find the gap in research and in numerous comprehensive studies problematic and underline the need for more effective rehabilitation programs.

Practical implications

A scoping review was conducted to thematically map the research in the area, identify any knowledge gaps deficit about PTSD and MI in Military personnel in Ukraine and contribute to further development of effective rehabilitation programs.

Originality/value

The sparsity of the existing literature highlights the need for further research into enhancing the mental health services provided to military personnel. In addition, there is a growing need to further explore trauma exposure and potentially morally injurious events related to PTSD and MI, in particular. Such a review has not yet been carried out, which adds value to the current paper.

Boken ger en unik summering av tio års forskning om militära veteraners hantering av stress före, under och efter utlandstjänstgöring. Det handlar om en kombination av akut stress, moralisk stress och ackumulerad vardagsstress. Ett panorama av stress­reaktioner presenteras liksom olika påverkande faktorer. Boken avslutas med 19 åtgärdsförslag riktade till enskilda personer, ledare, den militära organisationens högre chefer samt professionella aktörer inom hälso- och sjukvården. Den primära målgruppen är militära veteraner och potentiellt blivande sådana, såsom officerare, specialistofficerare, gruppchefer och soldater, liksom personer som utbildar sig till dessa yrken. Till de sekundära målgrupperna hör stödverksamheter inom Försvarsmakten och andra yrkesgrupper som riskerar att hamna i starkt stressfyllda situationer.

Purpose

The aim was to explore if self-rated psychological symptoms in military veterans covary strong enough with established PTSD scales to make a symptom checklist a useful screening tool.

Methodology

A Swedish sample of military veterans (n = 1,859) responded to a questionnaire which contained a checklist of ten psychological symptoms and a test of PTSD indication. The items measured the situation during the last month. All symptoms had the following response choices: 1 (Never), 2 (Seldom), 3 (Sometimes), 4 (Often) and 5 (Very often). The choices Often and Very often were combined and form the basis of the analysis.

Findings

The majority of individuals in the military sample reported that they had not experienced any of the ten psychological symptoms often or very often during the last month. Approximately 5% of the men and 9% of the women scored five symptoms or more. Among the men who reported five symptoms or more, about one third scored above a higher established PTSD cut-off value (PCL-4 > 44).

Originality

The psychological symptom checklist represents a new approach to PTSD indication screening and identification of individuals who may need further support.

Research limitations and strengths

Clinical assessment of PTSD would be a necessary complement for those that indicate further need. Study strengths include a large sample, use of established scales and a straightforward and simple statistical analysis.

Practical implications

The checklist is easy to administer and score. After a brief introduction, it takes about two minutes to complete.

Introduction: In the context of international military operations, officers andsoldiers are exposed to various service-related stressors that may have longlasting effects on their health and daily functioning. This study explored (1)the prevalence of symptoms indicative of both post-traumatic stress disorder(PTSD) and moral injury (MI), (2) the relationship between these conditions, and(3) the relationship between these conditions and a selection of backgroundvariables in Swedish military veterans who have previously been deployed inoperations.

Methods: The study was a self-report survey. Of 6000 individuals invited toparticipate, 1940 completed the questionnaire, resulting in a response rate of32%. Data was analyzed using correlation and regression analyses to explorepotential statistical relationships between variables of interest. Additionally, thedata were also analyzed using between-group analyses (t-tests) to examinedifferences between different groups.

Results: The results indicate that a low proportion of participants showed aprevalence of indications of PTSD, which are comparable to previous Swedishstudies on deployed veterans. An even smaller proportion was found to showindications of moral injury when compared to the assessment of PTSD. However,besides the small group that fulfilled the cutoff score criteria, a number ofrespondents reported milder symptoms of both psychological and moraldistress. The second goal of the study was to examine the relationship betweenindications of PTSD and indications of moral injury. The findings suggest thatthere is a considerable overlap between the two constructs. In addition, theresults suggest that the risk of PTSD and MI is highest when an event is perceivedas both highly stressful (fear-based) and morally challenging. The MI symptomsubcluster shame accounts for the largest variance in the PTSD indicator scalewithin the study sample. Health- and deployment-related background variableswere identified that may be related to indications of moral injury.

Discussion: The study results highlight the type(s) of stressful experience andthe health- and deployment-related factors that should be monitored postdeployment, which may serve as risk factors in developing indications of moralinjury. The higher prevalence of indication of PTSD and MI in the past month,despite receiving various forms of support upon returning from deployment,highlights the need for MI-specific treatment.

Sammanfattning

I samband med internationella militära insatser ställs officerare och soldater inför en variation av tjänsterelaterade stressorer, däribland traumatisk händelseexponering. Trots att post-traumatisk stresstörning (PTSD) generellt sett är välstuderat i en amerikansk militär kontext, vet man mindre om dess förekomst bland svenska militära utlandsveteraner som grupp. På likartat vis vet man lite om de hälsorelaterade effekterna av moraliskt utmanande situationer, samt vilka variabler som kan associeras med moraliska skador bland svenska militära utlandsveteraner.

Syftet med föreliggande studie var att bidra med fördjupad förståelse av hälsorelaterade utfall efter traumaexponering i samband med deltagande i svenska internationella militära insatser, med ett specifikt fokus på PTSD och moralisk skada.

Studien genomfördes som en enkätstudie. Data analyserades genom sambandsanalyser för att kartlägga potentiella statistiska samband mellan variabler av intresse. Data analyserades även med mellangruppsanalyser för att se om det fanns signifikanta skillnader mellan olika grupper som kan bidra till attförklara de orsakssamband som undersöktes. Relationen mellan PTSD och moralisk skada undersöktes också.

Erhållna resultat visar, liksom tidigare forskning på området, att svenska militära utlandsveteraner mår förhållandevis bra som grupp, samtidigt som det finns individuella variationer. En mindre grupp uppvisar förekomst av PTSD-indikation och en ännu mindre grupp förekomst av indikation på moralisk skada. Något fler än de som nådde upp till gränsvärdena för indikation, uppvisade aktiva symptom som kan relateras indikation på PTSD och moralisk skada. Risken för ohälsa tycks vara som störst efter traumaexponering när stressorer enligt Akriteriet(rädslo-/hotbaserad) och moralisk skada (skam, skuld, tillitsförlust) sammanfaller i en och samma händelse, samt då man själv varit direkt involverad ihändelsen och upplever att man själv gjort sig skyldig till något som står i kontrast till egna djupt hållna värderingar.

Studien visar även på flera individ- och arbetsrelaterade faktorer som tycks ha ett samband med långsiktiga hälsoproblem. Till exempel är individer som har sökt och erhållit olika former av stöd efter hemkomst från insats (såsom att ha sökt stöd, medicinerat för ångest, depression eller sömnsvårigheter, varit sjukskriven,etc.) överrepresenterade i den grupp som skattat sin hälsa som sämst under den senaste månaden. Den högre förekomsten av indikation på PTSD och MI trots att man erhållit stöd kan indikera ett behov av behandling specifikt inriktad mot moralisk skada.

Praktiska implikationer av erhållna resultat diskuteras.

Abstract

In the context of international military operations, officers and soldiers are exposed to a variety of service-related stressors, including traumatic event exposure. Although post-traumatic stress disorder (PTSD) is generally well-studied within an American military context, less is known about its prevalence among Swedish military veterans who have served abroad as a group. Similarly, little isknown about the health-related effects of morally challenging situations, as well as which variables may be associated with moral injury among Swedish military veterans.

The purpose of the present study was to contribute to a deeper understanding of health-related outcomes following trauma exposure in connection with participation in Swedish international military operations. This included a specific focus on PTSD and moral injury.

A survey study was conducted on Swedish military veterans who have served in international missions. Data was analyzed through statistical analyses including correlation analyses to map potential statistical relationships between variables of interest and subgroup comparisons to see if significant differences between different groups could help explain the relationships identified. The relationship between PTSD and moral injury was also examined.

The results obtained show, as with previous research in the field, that Swedish military veterans abroad are doing relatively well as a group, however, there are individual differences. A smaller group show elevated levels of PTSD indications, and an even smaller group show elevated indications of so-called moral injury. Some more individuals than those who met the cutoff thresholds for indication exhibited active symptoms that may be related to PTSD and moral injury. The risk of ill health appears to be greatest after trauma exposure that results in elevated symptoms related to both PTSD criterion A (fear-based) and moral injury symptoms (guilt, shame, loss of trust) in the same event. Specifically, when the individual has been the active party in the event and feels that they are guilty of something that is in contrast to their own deeply held values.

The study also shows several individual- and work-related factors that appearto be related to long-term health problems. For example, individuals who have sought and received various forms of support after returning from deployment (such as having sought support, taken medication for anxiety, depression or sleep difficulties, been on sick leave, etc.) are overrepresented in the group who rated their health as poorest in recent months. The higher prevalence of indications of PTSD and MI during the past month, despite having received various forms of support after returning from the deployment, may indicate a need for treatments pecifically targeted at moral injury.

Practical implications of the results are discussed.

The aim was to test a hypothesized model which indicates that a favorable balance between daily uplifts and functional coping on the one hand, and daily hassles and dysfunctional coping on the other, will be associated with fewer stress-related physical and psychological symptoms and a lower PTSD indication. An unfavorable balance was expected to show the reverse pattern. Questionnaire responses were obtained from 2512 Swedish military veterans (43.4% response rate). Four different statistical analyses were employed: bivariate correlations, multiple regression analyses, a cluster analysis and within-strata comparisons. All four analyses pointed to the same finding, a clear support of strong relationships between the balance box score and the frequency of physical and psychological symptoms as well as values on a PTSD indication scale. In addition, it appears as if the negative side of the balance box, a high frequency of perceived daily hassles and much use of an escape-avoidance coping style, account for stronger health associations than the positive side. Practical implications include that efforts should be made to limit the use of dysfunctional coping strategies, which, at least partly, can be trained, and to reduce a negative balance between perceived daily hassles and uplifts.

Our first aim was to explore the relationship between daily uplifts, daily hassles, and coping styles the first year after returning from international military missions and post-deployment work, family, and private reintegration in military veterans. Our second aim was to identify individual patterns regarding daily uplifts, daily hassles, and coping styles and to explore how they relate to the above-mentioned aspects of post-deployment reintegration. Questionnaire responses were received from 446 Swedish military veterans. Regression analyses showed that daily hassles and an escape-avoidance coping style made significant contributions in the predicted, negative direction to the amount of explained variance on reintegration indicator scales. A high level of perceived threat during the last mission also contributed to more negative integration. Using a person-centered approach, three unique profiles of response patterns were identified using a cluster analysis based on the uplift, hassles, and coping style scores. One profile was labeled “resilient and well-functioning”; its members showed favorable reintegration scores. A second profile was called “ambitious and struggling.” These individuals scored medium-high on the reintegration scales. The third profile consistently indicated the least favorable reintegration scores and was labeled “worried and avoidant.” The results confirm and deepen our existing knowledge.

A high number of military veterans seek professional help at primary healthcare centers for mental health problems. The main aim of this study was to map veterans’ perception of the quality of the care they received when seeking such help after their last tour of duty. A secondary aim was to explore personality and mission-related characteristics of veterans who seek professional help for mental health problems after missions. Questionnaire responses were obtained from 2512 Swedish veterans (43.4% response rate). Among the responders, 210 individuals had sought help for mental health problems at primary healthcare centers. Their perception of the quality of the healthcare was measured using the Quality from the Patient’s Perspective (QPP) questionnaire, which is derived from a theoretical model. Comparisons between the military help seekers and an age and gender matched group of civilian outpatients showed that the military group perceived the information they had received, and the commitment, empathy and respect shown by the physicians, considerably more negatively than the civilian patients. Comparisons between the help-seeking veterans and those who had not sought help, showed that the help seekers were younger and scored significantly lower on emotional stability and higher on conscientiousness. In addition, they perceived the leadership of their immediate commander during the last tour of duty more negatively and they reported fewer daily uplifts and more daily hassles during the tour. It was concluded that a more extensive collaboration between the armed forces and the healthcare system is strongly recommended and that it is necessary to provide education to healthcare providers.