Exploring Moral Injury Among Service Members’ Partners

Imagine facing a struggle that isn't just about the battlefield, but one that follows you home, affecting those closest to you. This episode opens up a much-needed discussion on how moral injury extends beyond PTSD, delving into the feelings of guilt, shame, and even spiritual crisis. Through ongoing research with the Moral Injury Support Network and Thomas Jefferson University, we gain insights from interviews with military spouses, exploring the profound impact on their mental health and relationships.

Personal stories of military families navigating the tumultuous waters of PTSD reveal a world of emotional upheaval and isolation. When a service member is diagnosed with PTSD, the ripple effects are felt by the entire family, creating a life that feels like an endless series of challenges. From the erosion of community and spiritual support to the financial and emotional strain, our conversations highlight the pressing need for comprehensive resources and understanding. The narratives shared offer a raw glimpse into the daily struggles these families endure and emphasize the moral injury experienced by spouses as they try to support their children amidst the chaos.

Turning from the stories to solutions, the episode emphasizes the moral duty felt by military spouses to support their loved ones and fellow families. We underscore the significance of moral injury-informed mental health services, peer support, and advocacy for better resources. This episode also connects listeners with organizations like the Moral Injury Support Network, encouraging active participation in securing vital support systems. Whether you're a military spouse, a veteran, or a care provider, the episode provides a wealth of perspectives and practical advice to help you navigate the complexities of PTSD and moral injury within military families.

Chapters

• 0:00 Exploring Moral Injury Among Military Families
• 21:10 Coping With PTSD in Military Families
• 32:56 Supporting Military Families Through Moral Injury
• 39:40 Military Family Support and Education

Transcript

Speaker 1: 0:34

Good afternoon, morning or evening, whenever you're watching this or listening to this podcast. Today, I want to talk about exploring moral injury among service members' partners. This is a study that's ongoing with Moral Injury Support Network and our partners at Thomas Jefferson University, and we've done a lot of work on this, and so I think it's a good time to share some of the findings that we have so far and some of the work that we've done, and encourage you to reach out to us for more information about moral injury among military families, because it is a major problem facing military families today, especially after so many years of war. So let's get into it today and talk about this. So this is not a project that I did alone. It included a number of team members, including myself and Kirby Wyckoff, who's a doctor of psychology with Thomas Jefferson University, and she is a co-principal investigator on this project. It includes Dr Sarah Archer, who is a very important research team member. She is compiling a book that we will publish this spring about our findings, about some of what we're going to talk to today and a whole lot more. Felicia Foligno has been with us from nearly the beginning, and this is research that's been ongoing for about four years or so, and Gareth Bone has also been with us very early from the beginning. We've recently added three more members to the team, but I didn't include them on this because they're just getting started with us and when this presentation was put together they were not yet with us. But it's a couple of more graduate students and another doctor who is helping us with the data doctor who is helping us with the data. We've interviewed 20 military spouses, so we have hours and hours of data to go through and we've compiled some of it in this presentation, but there's a lot more to come.

Speaker 1: 2:51

For sure, our objectives today are three main objectives we're going to understand the concept of moral injury, defining moral injury and explain how it differs from other psychological conditions such as PTSD. We're going to identify the impact on partners, analyzing the specific ways in which moral injury affects the mental health and relationships of service members' partners and Relationships of Service Members Partners. And we're going to explore support strategies, discussing effective support systems that can help partners manage the effects of moral injury. First, let's understand the concept of moral injury, define it and explain how it differs from PTSD. So Jonathan Shea was one of the first, if not the first person to coin the term moral injury and he defined it as a betrayal of what's right by someone who holds legitimate authority, like a military leader, for instance, in a high-stakes situation.

Speaker 1: 3:51

Jonathan Shea first encountered this phenomenon when he was working with Vietnam veterans after the war. That Vietnam was not a quote-unquote, clean war like we had with World War II, where there was a definite good versus evil kind of feeling to it. Vietnam veterans experienced a lot of Vietnam veterans experienced a lot of incidents and things that happened in the field that really bothered them, violated their sense of moral rightness A lot of times where they were betrayed or they were forced they felt they were forced to do things that were against their morals and they really struggled with it afterwards. So Jonathan Shea began to put this term together and began to research it, and since then other researchers have come along, including Brett Litz and his team. They defined it as perpetrating, failing to prevent, bearing witness to or learning about acts that transgress deeply held moral beliefs and expectations. Dr Nash, he said it's literal harm to a person or community as a direct result of betrayals of moral trust in high-stakes situations, in high-stakes situations and then what used to be called burnout in the military profession is now being seen as moral injury, or that moral injury is a definite component of it. You saw this for sure during COVID, when medical practitioners, doctors, nurses and so on were forced to provide care to sick patients what they were willing to do, but without the proper protection resources. Insurance is not covering things and so on. So, um, it's important to understand that moral injury is not um, has not. There's not any one definition, one one definition of moral injury that is um agreed to by everybody.

Speaker 1: 6:15

It's still, as a a research subject. There's still a lot of work to be done on it and my organization, moral Injury Support Network for Service Women Incorporated, we've done some research on moral injury. We interviewed 50 women veterans about their moral injury experiences. So we've done a lot of research. Our research on this, as well as the research of other folks, is in our four books that we published about moral injury, all of which are available on Amazon. But due to the early nature of moral injury as a research subject, there's still a lot of work to be done on it and a lot of defining to do. I mean, when you look at PTSD as a subject, we've been doing PTSD research for decades and decades and still there's definitely some arguments about it. So we don't ever expect moral injury to necessarily be something that everybody universally agrees upon, but it's important to know that it is something that is sort of an infant in terms of research.

Speaker 1: 7:31

Now, dr Hal Koenig at our conference he said moral injury has both psychological and spiritual dimensions. At our conference he said moral injury has both psychological and spiritual dimensions. So, as a spiritual problem, moral injury often guilt, shame and spiritual crisis often accompany moral injury, and so guilt over what you did or didn't do, shame over, maybe, what happened to you. A lot of women, veterans, experience this shame as a result of sexual assault, but shame, which is somewhat different than guilt, but they often accompany each other, they're together. And with moral injury we often see spiritual crisis, things like why did God let this happen to me? Or how could God allow this kind of pain and suffering in the world, that sort of thing. And so from a spiritual angle, you have these three things, and it's important to note that I'm saying spiritual, not religious, because certainly it can be a religious problem, but you do not have to be a religious person to be morally injured. As a psychological problem. It's very closely related to PTSD and we find similar symptoms such as emotional dysregulation, depression, anxiety and suicidal ideations.

Speaker 1: 9:41

Our study just to give you a little more insight on our study the overall aim of the project is to explore the phenomenon of secondary moral injury among spouses, ex-spouses, partners, or often the service member had never been diagnosed with PTSD but they certainly show all the signs and symptoms of it, and so we also included not just spouses but those who were ex-spouses. Some of the people that we interviewed lost their marriage as a result of the PTSD and moral injury and not everyone is married but they're still intimate partners and so we included those folks also. We've interviewed 20 spouses and ex-spouses so far and within that study participants described stressors, traumas, moral challenges they faced by living with service member, had extreme versions of PTSD, really traumatic stuff, and they suffered very much with know, social, either social isolation or being challenged in social situations. And so we didn't interview the service members. We interviewed the spouses, but the spouses described some of the things they experienced and some of the things they saw that their service members went through, and it's really important to note that, again, the service members had extreme versions of PTSD and that created a lot of suffering for the spouse and the family.

Speaker 1: 11:44

When we talked about moral injury, its definitions and so on with spouses, they linked moral injury to a combination of stressors multiple or frequent deployments, frequent moves, conflict between spouses, lack of holistic health care. You know, some of the service members moved every six months or a year or deployed six months or a year and came back for three, four months and deployed again. Some of the spouses or some of the service members were. A number of the service members were special operators and those who probably deployed more frequently than anybody else and this created a lot of stressors at home for those of you that are associated with the military, whether you're a spouse or were a spouse or a parent. I am, my wife and I are parents to a young Marine. My wife and I are parents to a young Marine, and so we understand the stress that can come with multiple, frequent deployments, long months or weeks without being able to hear from the loved one, wondering if they're okay and so on, and then having that service member come back from training or deployment um with a whole new language, a lot more use of the F word um a lot more stress and anger. Often they're dealing with and showing and feeling Um and and.

Speaker 1: 13:15

For spouses, you know it can be like walking on eggshells and just you know it can be uncomfortable to have the person around when they're, you know, triggered or you know feeling that anger or whatever. That often led to psychological and abuse and emotional abuse from service members. I love service members. I was one for 34 years. I love my son who's a great service member, a lot of great service members out there and I don't believe my son or I were ever physically or emotionally abusive. But the spouses did talk about those service members with PTSD, how abusive they could be at times. And you know when you're suffering from PTSD your mind is not always your own and so that can happen, is your own and so that can happen.

Speaker 1: 14:25

Spouses experience conflict between staying in relationships or protecting children because you know they worried about their children being exposed to the service member when they were triggered and having suicidal ideation and punching walls and yelling and you know being triggered when driving or that kind of thing and so on one hand they worried about what it was doing to them and their children should they leave and that sort of thing. On the other hand, they felt morally obligated to stay in the marriage because they felt that the service member served honorably, they protected the country, they served their nation and it wasn't their fault. They came back with PTSD. The service member was not to blame, but it still was very trying to stay in that relationship and very difficult. So all these things they link to moral injury as possibly causal or, you know, creating emotional trauma for the spouse and the children and the children.

Speaker 1: 15:38

Ptsd often accompanies moral injury, but the two phenomenons are different and that's an important thing to note. Both share shame and guilt as possible symptoms, symptoms, but moral injury often includes moral concerns. Did I do what was right? Did I, you know? Did I violate God's laws by doing what I had to do in war? Can I be forgiven that sort of thing? Betrayal by a feeling of betrayal by their leadership, by service members who were supposed to have their back? Women veterans talked about this a lot. They're sexually assaulted. It's like, hey, this it most often happened by a fellow service member and they're supposed to have my backs, not violate me, not harm me.

Speaker 1: 16:41

Loss of trust with command. Loss of trust with other people. Difficulty forgiving others. Loss of meaning, loss of identity. If I'm not able, if I'm because of what I did or because of what happened to me, or because of what I witnessed, or because of what happened to me or because of what I witnessed, what is the real meaning of the world? Their worldview can be shattered. What point is it? How you know? Is it worth it being a spouse or partner to this person? Who am I now, this person? Who am I now, now that I've done this, or now that I've experienced this?

Speaker 1: 17:30

One spouse talked about how, before the deployment that her service member came back with PTSD, she was very active in the church, and now that after the service member came back from PTSD, she no longer one didn't have time to be involved in church activities because her husband couldn't work. So she had to work, she had to take care of the kids, she had to take care of his health care, she had to pay the bills, so on and so forth. And so, you know, she could no longer identify as a devoted church person, and moral injury often accompanies self-condemnation what I did is so terrible, god could never forgive me. I'm a bad person, that sort of thing. And then we have, of course, religious struggles and loss of religious faith for those. Like one woman said, I'm just really pissed off at God right now Because and I can't just sit in the church pew and listen to a sermon that doesn't help me. And you know, her husband had an extreme case of PTSD, a lot of memory loss, and so she had so much pressure and stress on her all the time that she just and she couldn't see how God could be there or would help her. And so PTSD may not include these symptoms, and I don't say that definitively. Ptsd certainly may include some of those, but moral injury often includes all these things, whereas PTSD does not always. Ptsd does not always Okay.

Speaker 1: 19:25

So next we want to identify the impact on partners, look at specific ways in which moral injury affects the mental health and relationships of service members' partners. So we talked about this combination of stressors multiple or frequent deployments, frequent moves, conflict between spouses and lack of holistic health care. And when it comes to health care, there were a number of challenges. One of them was that simply there wasn't enough time for spouses to get the health care they needed. They were too busy working, taking care of the kids, providing for the service members' health care, just managing life, because they no longer had a fully functioning partner in the service member and so everything was on them, and then some of them, when they sought treatment, couldn't get it. It's difficult enough for veterans to get all the health care, and especially mental health care, they need. It's often a major challenge for them and we have a lot of veterans walking around not receiving enough mental health care and so in a family and the children not getting the mental health care they needed. So there's a huge lack of holistic health care. And in the US I can speak to the US, I can talk to some of my Canada friends too there's definitely some major gaps in health care for veterans, and that includes physical and mental healthcare.

Speaker 1: 21:10

So these stressors created a number of impacts on the family, including lack of stability, loss of friends and community. So if a service member was diagnosed with PTSD and then forced out of the service, then you have this whole lack of stability. You know the military active duty military does offer stability, housing. You know proximity to child care and schools and so on and so forth. But when you have to move away and you're no longer part of that military community because of the service member can't serve. That creates a stability loss and a loss of friends and community.

Speaker 1: 21:57

And some of the spouses talked about, you know, once the service member got diagnosed with PTSD then his fellow, his or her fellow service members did not want to be closely associated with them because they treated it almost like a disease. They all knew they were walking around with some mental problems. But to acknowledge that could mean losing your career and seeing a fellow service member lose their career because of it. It was like stay away. It sort of became persona non grata. A lot of anxiety and I talked about this before walking on eggshells, just feeling like the service member could get triggered at any moment. Anything the spouse or children said that could trigger something. Or riding in a car could trigger Some of the service member, could see a person of a certain ethnicity and become triggered, of a certain ethnicity and become triggered. So in these cases spouses were just surviving. They were not thriving. They were I say were or are, weary, just worn out all the time from all the stress, all the responsibility. Having to do it all on their own and I mentioned before this led to a loss of faith for many of them.

Speaker 1: 23:32

One participant said we moved gosh 14 times during my husband's career. So I mean we didn't even have a stereotypical military career. My husband was home for less than three total months of that two and a half year tour. I would consider moral injury to be primarily what I was willing to allow my children to go through. You know, just living the way they've had to live with all the upheaval and that can be really hard on kids. You know, in my military career Patty and I made the decision to not move around. I moved around, the kids and Patty stayed here where we live so they could have continuity of school, friends and so on, and we felt that was better for them. But then they had to live with the difficulty of me being gone a lot and sometimes me being stationed hundreds of miles, more than a thousand miles away and only getting to see each other occasionally, and so the military lifestyle can be very difficult. But when you add PTSD to the mix you have a whole, whole, whole new kettle of fish that can be really, really trying in terms of physical and emotional abuse.

Speaker 1: 24:50

Service members were withdrawn, isolated from family, frequent, raging, physically or verbally abusive to partners and children, and that left family members to live in a state of constant fear, not only fear of what the service member might say or do to them, but fear of if the service member was going to die by suicide if they, you know, sometimes the service members would just disappear for hours or even days at a time and fear of financial fears If the service member got triggered, went on a spending binge. I mean, these kind of things happen. Service members often came withdrawn and so did spouses and children could be withdrawn from their friends and family because not wanting to have to explain what's going on with that or what's going on with the husband, have to answer all these questions about things that they didn't want to talk about. Anxiety and depression was a common thing. To talk about Anxiety and depression was a common thing, and then children often acted out in various ways because of the stress and not knowing. You know really how to manage those things.

Speaker 1: 26:18

If we're going to talk about PTSD and the outbursts and the anger and you know the impatience, the things that he's reacting to are not big scary triggers. It's not the fireworks on 4th of July. It's being angry because you know the walls aren't painted as well as he'd like them or something stupid like that. So so it was often the little things that were triggering, not the big things and those little things that were triggering, not the big things and those little things. Those triggers could happen at any time. Some more quotes? No, not really, I think. You know it's a battle every day. Not a battle, but it's a walking on eggshells every day, trying to figure out what the mood is, what would the service member, what was their mood today, and just walking on eggshells. It's a hard way to live.

Speaker 1: 27:05

Another one said I've learned that some of the things that we did go through in those early days are considered abuse. I'm not going to tolerate that again. I mean, I had things thrown at me. There's holes in the walls, tiles broken. I've had to call law enforcement, you know, just to protect him. Mostly, um, I think I'm just holding a little bit of a grudge, a lot of grudge, an eight-year one.

Speaker 1: 27:31

At this point, I think that I'm just not ready to sit there in church and be like, oh, these things happen for a reason. God does these things for a reason, and that's what one person said. She grew up as a Catholic but after her husband came back with PTSD, things changed tremendously and we hear those. For those of you that grew up in church, you heard a lot. Things happens for a reason. God does things for a reason and that's not very useful when you're going through so much trauma. It just it doesn't sit well. And another person said I felt that God, should, you know, be guiding me and I didn't hear his voice anymore. And when I stopped hearing his voice I just went into a really dark period. So she was used to having this sort of relationship with God where she felt she heard his voice regularly, that he was guiding her and leading her. And with so much trauma, pressure and so on, she felt like that voice became silent when she needed it the most. And you know, I'll leave it up to theologists to sort out why that happens, but I can say from my own experience that when you're under a lot of stress and pressure, it can be like that stress and pressure fills your brain so much you can't hear any voices, let alone God's, and so it just feels like you're all alone for those people.

Speaker 1: 29:10

As we mentioned, there was a moral conflict with the service members. They didn't blame the service members for PTSD and I'm not blaming them either. You know, when you go through those kind of experiences, you serve the nation honorably but yet go through so many things during deployments, or betrayed by your command or whatever um that can, um, that's not your fault. Some felt obligated out of a religious or sacrificial love beliefs. In other words, they felt like if you really self love someone, you'll be through them thick or thin. Um, you'll be with them thick or thin, you'll be with them, no matter what, and that's sort of the marriage vows we take. And so there was a real conflict for them because they felt like they would be betraying what God might be calling them to do in living in this situation. And they felt like they did love the service member. They wanted to love them and care for them, but it was just so hard and so it created this conflict.

Speaker 1: 30:19

We find that, with moral injury, often is a conflict between two bad choices, maybe oftentimes. And then there was this feeling of if I don't help my service member, who will? And that's a really good question because, like I mentioned, a lot of service members couldn't get the care they really needed and they needed help getting care, they needed help managing their life, and so if the spouse just took the children and left? There wasn't children in every situation, but just left and left that service member on their own who's going to take care of them? And that would feel like its own version of betrayal. And they wondered about the long-term effects on children. How am I burdening my kids by going through this stress so early on in their life?

Speaker 1: 31:22

Some of them learned later to enforce boundaries to prevent abuse. They learned that if I'm going to stay with this person, I have to set boundaries and enforce them so that to protect myself and my children. But that lesson came hard and it came often later. Um, they wanted to escape the constant stress and pressure, but it was there every day. Uh, and it's with them all the time. I wondered, uh, one woman said.

Speaker 1: 31:53

I wondered if staying was the right answer because it vastly affected how my children were raised. Trying to teach them that what was normal for dad it's not normal for everybody and that it's still not okay that we have to accept that If you choose to be in a relationship, you have to accept both pieces, the good and the bad. And then you have to learn to live and accept what's not always positive. So how would I teach them that lesson in life if I just walked away from my husband because I don't like this new reality of his? That's a tough question. Not everybody's going to agree with that approach. Some people say, hey, if there's abuse or if there's trauma, you got to leave. But it's not an easy decision and there's that pull of you know what kind of example am I setting if I'm staying? What kind of example if I'm setting if I'm go? You know, what am I doing to my children by staying here? Really tough questions that only the person themselves can answer for sure.

Speaker 1: 32:56

I think, like my moral, my own moral obligation to try to do the right thing this is what one spouse said is a driving force in a lot of this. You know, just not necessarily just for my husband, but for those peers and for other veterans that come into our lives, for our son. You know I just not necessarily just for my husband, but for those peers and for other veterans that come into our lives, for our son. You know, I just feel like I owe it to everyone to find different treatments and medications and doctors and healthcare and all these things that contribute to hopefully the best possible outcomes for us all. And as I interviewed these women, they weren't all. They weren't all women for sure, but mostly. But as I interviewed these women, they weren't all women for sure, but mostly. But as I interviewed these spouses, I gained a whole new respect for them, because I thought I don't know if I could go through what they have gone through. I don't know if I could do it, and they managed to do it day in, day out, and so, all right, let's explore some strategies that can help partners manage the effects of moral injury, and we're just going to really hit the wave tops on this.

Speaker 1: 34:05

I encourage you to reach out to my organization, moral Injury Support Network. You can find us on Facebook, you can find us on the web at misnsorg. You can reach out to me at droberts at misnsorg. But there's certainly a greater need for psychology and psychiatric services. Not enough for veterans. There's not enough, certainly not for spouses. We need moral injury-informed mental health and chaplain support. It's not just enough to provide support, but if care providers don't understand moral injury, they're likely to not be able to provide the best care possible, and so there's a need for more training and education on moral injury and and how to provide health support to somebody who's morally injured. My organization provides that training, others do but but we do provide training that is customized for care providers. It's customized for the organization. If you reach out to us, we can help you with that. Peer support was a very effective way to help spouses. There's some really great peer support groups out there. We can help you find those and point the way to those if you're interested in that.

Speaker 1: 35:33

There was a need for child care, transportation services, food and financial support, and that wasn't always available. And child care is a really tough one and child care is often limited to certain ways that child care can be provided or given. It wasn't always convenient enough, effective enough or available enough for these military family members where PTSD was a factor, and so I'm working, partnering with some organizations on the childcare issue, but there's a lot to be sorted out with it and that's an area we continue to work at. Food and financial support you know finances were often very strained with these families because now you have one breadwinner, you may or may not have a service member who's receiving disability payments, but even then those only go so far, and so financial support definitely needed and there's a need for education for family members on PTSD and moral injury, how to access services, establishing and enforcing boundaries and other kinds of things. Again, not to toot our own horn, but we do provide this kind of training. Be happy to help with it. But there is definitely a need for family members to understand what is PTSD, what is a moral injury? How can I protect the service member, as well as myself and children with these boundaries? How do I access care, all those kind of things? And it's not always easy. A lot of service members or the families moved away, as I mentioned before, from military installations and that made it even more difficult to get care.

Speaker 1: 37:21

Some more notable quotes here. We just need information. You know there are people who are 19 to 21 years old. Nobody should have to fight for proper care because not everybody has that fight in them. You know some people have to work full time. I'm lucky I can make that battle every day. Some people have to go to work and they still have to figure it out.

Speaker 1: 37:42

Another person said I tried to go when my husband was first suicidal. I was having panic attacks and so I went into family practice. I got my referral to go to mental health. I spilled my guts and I just word vomited everywhere for like 40 minutes. By the time I finished that appointment she was like you know what, considering all that's going on, I think you're doing pretty well and she would not give me a full referral to mental health. And that's just negligence, that's just I. That angers me. But if this happened to one person, it can happen to others, and it it it illustrates how difficult it was. Can you imagine that kind of abandonment the spouse felt and and the kind of like hopelessness that they felt because they couldn't get? They finally decided to try to get mental health care and that's what the answer they got. Come on Some more quotes.

Speaker 1: 38:39

I'm there advocating for myself and other caregivers and fighting to get our veterans what they need. I shouldn't. It shouldn't be that we always have to fight the VA. It shouldn't be that way. I think it's come home more to me, you know. I know that I'm going to have this the rest of my husband's life. We're going to have to be dealing with this. So I'm a little bit on fire myself, but I have these buckets of water, wisdom, resources, support, lessons learned that are the meaning of all of this kind of tough stuff. If I can help other people put their fires or make their fire smaller, then I'm going to do it. So that's that peer support piece, really important and that's an effective way. Okay, we'll skip these slides because that's that's. We'll skip these slides because that's some questions I asked that are live. On that we did All right, finishing up here.

Speaker 1: 39:38

We provide organizational training.

Speaker 1: 39:40

I mentioned that before you can reach out to us this email, the two emails here.

Speaker 1: 39:46

Kirby is a trainer with me.

Speaker 1: 39:50

We've trained this together a number of different times, done continuing education events for care providers a number of times on this topic.

Speaker 1: 40:01

We also have other people in our organization that can do training and Sir Archer is a very great trainer and so we're happy to help with training needs as we go forward, and so hope this video helps you, or this, if you're listening to this on a podcast, this really helps you and really all this does it kind of gives you some starting information, really helps you and really all this does it kind of gives you some starting information. It gives you a sense of really the difficulties that are being faced by military families where PTSD is a factor, how moral injury plays into it. We'd love to talk to you more about it. You don't have to be a care provider to reach out to us. You might be one of those military spouses that's struggling and needs some help. We're happy to help with that. You might be a veteran that wants to understand moral injury more. We can help with that. So we're there for you. Reach out to us. Enjoy the rest of your day, have a great week and until next time.