As a Deployment Behavioral Health Psychologist with the Center for Deployment Psychology, one of my specific areas of interest is that of suicide. I am fortunate enough to be able to teach pre-doctoral interns and civilian mental health providers about suicide prevalence, theory, associated risk and protective factors, as well as treatment. In addition, I work in a military treatment facility, so I see patients and supervise interns with their caseloads. As a result, I have naturally seen many Service members and Veterans presenting for treatment with histories of trauma and associated PTSD, depression, relationship problems, work problems, and other mental health consequences. After a couple of years of exposure to this population, I began to notice that many Service members exposed to trauma had prominent depressive symptoms and feelings of guilt or shame about things they had done or had not done during deployment that conflicted with the values of their upbringing. Also, I heard Service members’ stories of witnessing these types of events. We now call this “moral injury” and research in this area is enlightening the field and the public about a subset of trauma-related problems that don’t quite fit the typical picture of PTSD. Yet, those who have experienced a moral injury can, in my opinion, be the most difficult to treat. This is may be due to the overlay of shame and the upheaval of one’s self-concept as a result of being a part of activities that go “against the grain” of what they previously believed. Also, witnessing events that lead to moral injury can dismantle one’s faith in humanity’s moral compass in general, leading to depression and an increased risk of suicide.
Among the research in the area of moral injury and suicide is a study by Bryan, Theriault, and Bryan (2014) which sought to understand further the relationship between moral injury-related concepts and suicide. Specifically, the authors wanted to look at self-forgiveness (conceptualized as a mechanism by which guilt and shame are reduced) as a protective factor that reduced the risk of suicide or moderated risk factors for suicide. Overall, their three hypotheses were:
Subjects included college students (i.e., enrolled in college classes) who were also military personnel or veterans. All branches of service were represented. Although most subjects were male (69.2 %), the age range (19 to 78 years) was wide. Most subjects were white (81.4%) with African Americans representing 6.1% of the sample, Native Americans representing 3.2%, Asian Americans representing 2.5%, Pacific Islander representing 1.1%, and Hispanics representing 10.8%. Participants completed measures inquiring about previous suicidal ideation and attempts (Self Injurious Thoughts and Behaviors Interview), depression (Patient Health Questionnaire-9, symptoms of PTSD (six items from the PTSD Checklist), self-forgiveness (a subscale of the Heartland Forgiveness Scale), and trauma exposure (the Life Events Checklist).
Two of the authors’ hypotheses were supported. First, greater self-forgiveness was associated with significantly less post-traumatic stress regardless of exposure intensity suggesting that self-forgiveness may be a trait which is protective among Service members and Veterans, even if exposed to repeated traumas. They also found that self-forgiveness is positively correlated with age, suggesting that people become more compassionate toward themselves as they age, even though they may have experienced more trauma. The authors’ prediction that self-forgiveness would be lower among those with a history of suicidal ideation and attempts was also supported. This is consistent with prior research suggesting that moral injury and risk for suicidal ideation and attempts are linked. The authors suggest that related to this, moral injury may be a mechanism that contributes to the relationship between post-traumatic stress and suicide risk among Service members.
The authors point out that the findings of this study provide additional support for Rudd’s Fluid Vulnerability Theory which states that positive internal beliefs (e.g., self-forgiveness) should reduce one’s vulnerability to suicidal crises. They also note that in the suicide literature, many empirically supported suicide risk factors are actually risk factors for ideation, not behavior. However, in this study, depression was a better predictor of suicide ideation, but self-forgiveness was a better predictor of suicide attempts. The authors suggest that this is important and may be helpful in determining which individuals go on from ideation to attempts. However, this is a preliminary suggestion at this point.
Moral injury is an important clinical concept, and research is beginning to focus on specific components that comprise this response to trauma and how it may be related to suicide. Based on this study, self-forgiveness, being inversely related to the shame and guilt that comprise part of the picture of moral injury, may be a buffer against suicide attempts. These authors suggest that implementing interventions that promote self-forgiveness may be an important treatment focus among military members and Veterans.
Bryan, AnnaBelle, O., Theriault, Jacqueline, L., Bryan, Craig J. (2014). Self-forgiveness, post-traumatic stress, and suicide attempts among military personnel and veterans. Traumatology, 21 (1), 40-46.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Dr. Regina Shillinglaw is a deployment behavioral health psychologist with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Located at Wright Patterson Medical Center in Ohio, she is a faculty member and the assistant training director in the APA-approved pre-doctoral psychology internship training program.