The impact of trauma exposure and moral injury on UK military veterans: a qualitative study

Figures & data

Table 1. Participant demographic information

Index	Total sample (n = 30)	Moral injury veterans (n = 15)	Mixed veterans (n = 9)	Trauma exposed veterans (n = 6)
Mean age, M(SD)	46.3 (12.4)	43.6 (10.6)	51.6 (16.1)	45.3 (9.2)
Marital status, n (%)
Single	5 (16.7%)	3 (20.0%)	1 (11.1%)	1 (16.7%)
Married/living with partner	18 (60.0%)	9 (60.0%)	6 (66.7%)	3 (50.0%)
Separated/divorced/widowed	7 (23.3%)	3 (20.0%)	2 (22.2%)	2 (33.3%)
Branch, n (%)
British Army	28 (93.3%)	15 (100.0%)	8 (88.9%)	5 (83.3%)
Service branch, n (%)
Regular	26 (86.7%)	13 (86.7%)	7 (77.7%)	6(100.0%)
Rank, n (%)
Officer/non-commissioned officer	15 (50.0%)	6 (40.0%)	7 (66.7%)	2 (33.3%)
Junior rank	15 (50.0%)	9 (60.0%)	2 (22.2%)	4 (66.7%)

Moral injury veterans = veterans who self-reported exposure to a PMIE. Mixed veterans = veterans who self-reported experiencing a ‘mixed’ event where the event was both potentially morally injurious and traumatic/life-threatening. Trauma-exposed veterans = veterans who self-reported experiencing a traumatic or life-threatening (non-morally injurious) event.

Table 2. Themes and subthemes following thematic analysis

Themes and subthemes	Verbatim quotes
Experiences of morally injurious and non-morally injurious trauma	‘[During] my first two tours things happened, one or two things I did. I often have questioned myself about it whether I took the right decisions or not … occasionally you are in the middle of a riot when you’ve got 12 [soldiers] and you are trying to deal with 250 [people] who are all throwing bottles, bricks and everything else at you – men and women. Again, you sometimes … do things that perhaps are quite heavy handed which retrospectively you think should I have done that? Or should I have approached it in a different way?’ (Male, 63 years, mixed)
Impact of morally injurious and traumatic events on cognitive appraisals
Crises of moral dissonance	‘If I was to go into a town and shoot five people, I would be a mass murderer. Yet if I was to shoot five people in uniform overseas you are legally entitled to do that because you have rules of engagement and all the rest of the stuff. But murder is murder at the end of the day. Killing is killing.’ (Male, 47 years, moral injury)
Prevention of moral dissonance	‘It came over the radio, “oh we’ve got a bravo down here, he’s injured. We’ll need the med in to get him out.” … Someone decided that no, hang on a fucking minute, we’re not having a [helicopter] come out into hostile territory to recover somebody who is trying to kill us … And from people at the site, they’ve basically come back and said he just stood … .until he stopped breathing. Obviously, that’s just murder, there’s no two ways about that. But in terms of right or wrong, it was right to do that … we were risking a helicopter full of people to come in to extract somebody who had been trying to kill us, which could result in more of us being injured or killed.’ (Male, 36 years, moral injury)
Resolving moral dissonance	‘Eventually I came to this conclusion of where do I go with this? Do I keep feeling bad about it? … I was like, I’ve read about how this ends with other people and you hear about people taking their lives and stuff … and I’ve got no interest in doing that so I need to decide what I’m going to do with this. I decided to move past it … I don’t want to sound flippant because that kid died, it was a bad thing, a terrible thing, but it’s done. I can’t help myself by thinking about it all the time and being sad about it all the time … If I choose to mourn that kid for the rest of my life everyday it’s not going to help me in any way. You know? And that was the realization I think that changed things.’ (Male,36 years, moral injury)
Effect on negative appraisals	‘When we were walking around and supposedly protecting and serving … you didn’t know who or what to trust or who was watching you, who wasn’t watching you. You were hiding in plain sight. So, then your world view becomes a distrust.’ (Male, 46 years, trauma)
Implications for psychological wellbeing	‘So, yes, it does make you question who and what you are, and you shouldn’t really be like that. Then I suppose you spend time trying to make amends and so forth … I mean in a very belated and very pitiful way; I found the guy’s grave and put a little cross on it.But what I try to do now is to find work with one of the military charities helping veterans move into jobs and so on.’ (Male, 62 years, moral injury)
Effect on posttraumatic growth	‘I’ll be honest, I’ll sometimes ask God for a favour and as they say there’s no such thing as an atheist in the trenches. There is something there that I can’t explain … so spiritually I think it may have actually made me a better Christian.’ (Male, 63 years, mixed)
Risk and protective factors for experiencing a moral injury	‘You know right from wrong … [but] it’s the consequences of your actions, that’s what you don’t know. You don’t know how it’s going to impact you and I think the Army should really drill that into you in the career’s office … I think it’s your age. I think it’s how mature you are as a person … I wasn’t a very mature 19-year-old. Whereas somebody [who] probably is very mature and then they could deal with it differently.’ (Male, 31 years moral injury)