When we think of war, we tend to think of the physical carnage it causes, but what about its moral effects? A study published in the Journal of Psychiatric Research explores whether acting against one’s morals while serving may be related to pain intensity in veterans.
War is a very traumatic event, and it is no secret that many veterans struggle with posttraumatic stress disorder as a result. Another less commonly considered outcome after war is having moral injury, which is results from having experiences that go against deeply held beliefs or morals.
This could include anything from committing violence to witnessing something wrong and being unable to prevent it. Moral injury has been believed to have a relationship with chronic pain for veterans, but the research has been scarce. This study seeks to bridge that gap in literature.
For their study, Rachel M. Ranney and colleagues utilized data from 11,871 American veterans from the Comparative Health Assessment Interview Research Study. Data for this study was collected in 2018 online and/or over the phone. Participants completed measures detailing demographic information, moral injury events, posttraumatic stress disorder criteria, combat exposure, adverse childhood experiences, joint and muscle pain, and pain intensity. Moral injury has three subscales: witnessing, perpetration, and betrayal.
Results showed that PTSD symptoms were related to increased joint and muscle pain, as well as higher levels of pain intensity. Witnessing and perpetration of morally injurious events were not found to have a relationship with pain, but feelings of betrayal were related to higher intensity of pain even when all other variables were controlled for.
Upon further analyses, this relationship existed for female veterans only. Betrayal (such as sexual assault by a close other) differs from witnessing and perpetration because it causes harm to the person experiencing it, which may explain why it is the only factor associated with physical pain. This is consistent with previous research that traumas that involve high levels of betrayal lead to more negative health outcomes.
This study took important steps into better understanding moral injury in veterans. Despite this, there are limitations to note. One such limitations is that this study is cross-sectional, not longitudinal, and exploring temporal relationships would be very useful in this situation. Additionally, the types of pain assessed were very limited; future research could include more common sources of pain, such as headaches.
“This is the first study to our knowledge to investigate relationships between different types of [potentially morally injurious events] and chronic pain. Our application of population weights enhances confidence in the generalizability of results to the national population of post-9/11 veterans,” the researchers concluded.
“We found that betrayal (but not witnessing or perpetration) was associated with pain intensity, even when controlling for PTSD and other relevant factors. Regarding gender differences, we found that among women, betrayal was associated with joint pain and pain intensity, but among men, betrayal was not associated with any pain outcome. Thus, it may be important to assess betrayal when treating patients—especially women patients—with PTSD and/or chronic pain.”
“Psychological effects of betrayal may play a role in the development and maintenance of chronic pain as well as PTSD,” Ranney and colleagues wrote. “Providers treating patients for pain who may also have a history of trauma for pain should be aware of psychological treatments, such as evidence-based psychotherapies for PTSD, that target psychological factors that may maintain and exacerbate pain.”
The study, “Moral injury and chronic pain in veterans“, was authored by Rachel M. Ranney, Shira Maguen, Paul A. Bernhard, Nicholas Holder, Dawne Vogt, John R. Blosnich, and Aaron I. Schneiderman.