Isolating effects of moral injury and low post-deployment support within the U.S. military

Highlights

• Other-transgressions and low support combined may lead to thwarted belongingness.

• Betrayal and low support combined may lead to thwarted belongingness.

• Unexpectedly, self-transgressions may not lead to thwarted belongingness.

• Moral injury, especially other-perpetrated, should be assessed and treated.

Abstract

Suicide rates within U.S. military components, particularly the National Guard, are significantly higher than the general population suicide rate. To better understand and prevent suicide within this population, we must identify mechanisms of risk contributing to these discrepancies. One risk factor relevant to military service is moral injury, a term for experiences that violate one's moral beliefs. Using a series of hierarchical multiple regressions, the current study examined the moderating role of post-deployment social support on the association between moral injury (self-transgressions, other-transgressions, and betrayal) and thwarted belongingness among military personnel. The current sample was comprised of 552 military personnel with at least one previous deployment. Partially consistent with hypotheses, results revealed that other-transgressions and betrayal were significantly associated with thwarted belongingness at low, but not mean or high levels of post-deployment support. In contrast, the interaction of self-transgressions and post-deployment support was not significantly associated with thwarted belongingness, nor was there a significant main effect of self-transgressions on thwarted belongingness. This suggests that experiencing other-perpetrated morally injurious events (i.e., watching a fellow soldier die, being betrayed by a comrade) can be compounded by low post-deployment social support, increasing risk for thwarted belongingness. Implications for prevention and treatment are discussed.

Introduction

The suicide rate among United States military personnel is significantly higher than that of the general population. For example, in 2013 the suicide rate in the active component of the military was 18.7 soldiers per 100,000 and the suicide rate in the National Guard component was 28.9 per 100,000 (Smolenski et al., 2014). In contrast, the suicide rate in the general population in 2013 was 13.0 people per 100,000 (Centers for Disease Control and Prevention, 2003). Despite a downwards trend in the suicide rate among members of the National Guard in 2014, the suicide rate among military personnel continues to be elevated relative to that of the general population (Pruitt et al., 2016). In order to understand this discrepancy, the unique experiences of military personnel must be taken into account. In the year 2013, 90.2% of suicides among military personnel occurred domestically, with 66.5% of suicide decedents having a service history with at least one deployment (Smolenski et al., 2014). These findings indicate that military personnel with a history of deployment may experience increased suicide risk after reintegrating into the general population, particularly in the National Guard, where soldiers separate from their units after deployment. Indeed, this type of time-dependent vulnerability was noted in a longitudinal study by Kapur et al. (2009), who found suicide risk was greatest in the two years following military discharge. Understanding the way that experiences during deployment interact with post-deployment experiences may further illuminate the mechanisms of suicide risk in this population.

The interpersonal theory of suicide (ITS) is one framework through which the elevated military suicide rate can be understood (Joiner, 2009). This theory identifies two components necessary for suicide: desire for suicide and capability for suicide. High levels of capability for suicide, a construct which is characterized by fearlessness about death/bodily harm and elevated physical pain tolerance, have been found among military personnel, particularly among military personnel with combat experience (Bryan et al., 2010a, Bryan et al., 2010b). According to the ITS, capability must occur in the presence of desire for suicide in order for an individual to attempt suicide (Joiner, 2009), so it is imperative to prevent the development of suicidal desire within this highly capable population.

Within the ITS framework, desire for suicide is characterized by perceived burdensomeness and thwarted belongingness, combined with hopelessness that these emotional states can or will change. The primary component under investigation in this study, thwarted belongingness, is characterized by a perceived lack of reciprocal social relationships and feelings of isolation (Joiner, 2009). One way military personnel may develop these feelings is through the experience of moral transgressions during deployment. Moral transgressions are acts that one perpetrates, experiences, or witnesses that contradict one's moral beliefs and/or expectations. During combat, military personnel often experience morally offensive acts, such as killing enemy soldiers, witnessing injuries and death, or finding human remains (Litz et al., 2009). Although these experiences are somewhat anticipated due to the nature of warfare, they may still have lasting impacts on the psychosocial adjustment of military personnel (Selby et al., 2010). Importantly, moral injury is a concept related to, but separate from, Post-Traumatic Stress Disorder (Kopacz et al., 2016). Current theories of PTSD can only partially explain the development of moral injury, as it is a complex reaction to the perpetration, experience, or witnessing of human-generated harm (Litz et al., 2009). Due to the interpersonal nature of moral transgressions, soldiers may anticipate abandonment by established social supports or be more reluctant to utilize available supports, particularly if they perpetrated the moral transgression(s) (Litz et al., 2009). In some cases, military personnel may actually experience such ostracism from military and/or civilian social supports.

Past research has indicated that suicide risk factors among military personnel are similar to those found among civilians (e.g., male sex, depression, alcohol-related problems; LeardMann et al., 2013) and has also found that deployment history/combat exposure is not differentially associated with increased suicide rates among military personnel when compared to those with no deployment history (Bryan et al., 2013). However, it has been suggested that certain consequences of deployment, such as the development of mistrust due to combat experiences or fear of being viewed negatively for fighting in an unpopular war, may increase feelings of isolation from others, which can in turn increase suicidal desire (Selby et al., 2010). Therefore, it is possible that deployment experiences, such as moral transgression, affect the development of suicidal ideation/suicidal desire by way of decreasing sense of belonging. Indeed, Bryan et al. (2014) found that experiencing moral injury is a risk factor for suicidal ideation and suicidal behavior among military personnel, highlighting the potential relevance of moral injury in the development of suicidal desire. More specifically, experiencing or witnessing atrocities during deployment (e.g. excessive cruelty or violence) is more strongly linked to later development of psychopathology and suicidal behavior than is combat exposure alone (Litz et al., 2009). This lends further support to the notion that an aspect of the deployment experience, moral transgression, may contribute unique risk to the development of suicidal desire among military personnel.

An emotion that is linked to the experience of moral transgression is shame. This emotion often leads to social withdrawal and can inhibit interpersonal interaction (Litz et al., 2009). Feeling shame after experiencing moral transgression may therefore lead to increased isolation from social supports, which can serve to increase suicidal desire. Another emotion associated with moral transgression is guilt (Litz et al., 2009). It is possible that guilt about one's actions during war contributes to increased feelings of thwarted belongingness (Selby et al., 2010, Bryan et al., 2013). Additionally, military personnel may have extreme difficulty coping with the effects of moral transgression when separated from the military culture, which may act as a contextual aid to make these experiences more comprehensible (Litz et al., 2009). In this way, returning home may worsen the effect of moral transgression due to perceived or actual lack of understanding on the part of civilian social supports.

Past research has found that transitioning home after service and/or deployment is difficult for many military personnel (Brenner et al., 2008, Anestis et al., 2009). In fact, in one qualitative study, veterans indicated that strong bonds are formed with other military personnel during service, but an individual's connection to civilian life decreases (Brenner et al., 2008). This may serve to isolate returning soldiers from potential civilian supports, which is especially concerning because these individuals will no longer have easy access to the military social supports to which they are accustomed. Several studies have found that a lack of perceived post-deployment social support moderates the relationship between combat experience and negative outcomes, including the development of PTSD, increased PTSD intensity, and suicidal ideation (Solomon et al., 1988, DeBeer et al., 2014, Pietrzak et al., 2010). These findings indicate that perceived lack of connection to family and friends and/or self-withdrawal from others after returning from military service can decrease sense of belonging, which can result in risk for psychopathology and suicidal desire. Although it has been established that decreased post-deployment support increases risk for suicide, the interaction of low support and moral injury during deployment has not been investigated.

The primary aim of this study is to examine the relationships between facets of moral injury (other-transgressions, self-transgressions, and betrayal) and thwarted belongingness. Also under investigation is the impact of post-deployment social support on the strength of the relationship between moral injury and thwarted belongingness. It is expected that moral transgressions will be associated with thwarted belongingness and that post-deployment social support will moderate this relationship, such that low levels of support will heighten risk. In order to examine these relationships, a study was developed with military personnel primarily drawn from the U.S. National Guard, a branch with an elevated suicide rate relative to the active duty component of the military (Smolenski et al., 2014). Support for these hypotheses would highlight the impact of deployment-related experiences on the psychosocial adjustment of military personnel and may emphasize the need for improved social support for those returning from deployment or following discharge from the military.