Chronic Pain, PTSD and Moral Injury in Military Veterans: Suffering and the Compromised Self
Abstract: Veterans with chronic pain may face complex additional challenges, notably the potentially high rate of comorbid post-traumatic stress disorder. Linked to this is the developing concept of moral injury, essentially feelings of guilt and shame associated with transgressing one’s moral beliefs. Work has begun to explore moral injury in the context of psychological trauma, however it has not to date been considered in relation to chronic pain. As the moral injury concept is still developing, this paper explores what is known about the roles of guilt and shame in psychological trauma and chronic pain, and aims to set this in a military context, to begin to understand clinical implications and to make recommendations for further research. A search of the literature reveals that guilt and shame in psychological trauma and chronic pain are not well understood, and research has predominantly focused on these as consequences, rather than as potential contributory elements. Literature is currently separated, focusing either on PTSD or on chronic pain, and we suggest a more integrated approach is required.
Abstract: Background: Exposure to potentially morally injurious events (PMIEs) during military service can lead to moral injury (MI) outcomes and posttraumatic stress symptoms (PTSS). This longitudinal study examined the relationships between PMIE exposure, MI outcomes, and PTSS among Israeli combat veterans, and the potential protective role of dispositional forgiveness in these associations. Method: Participants were 169 Israeli combat veterans who participated in a six-year longitudinal study with four measurement points (T1: 12 months before enlistment, T2: Six months following enlistment- pre-deployment, T3: 18 months following enlistment- post-deployment, and T4: 28 months following discharge). Participants’ characteristics were assessed via semi-structured interviews (T1) and validated self-report measures (T2-T4) between 2019-2024. Results: Approximately 36% of participants reported exposure to PMIEs during service, with 13% exceeding the clinical threshold for probable PTSD at T4. PMIE-Betrayal at T3 was positively associated with MI outcomes of shame and trust violation at T4. The indirect effect of PMIEs on PTSS through MI outcome-Shame depended on forgiveness levels. Among veterans with low forgiveness, higher exposure to PMIE-Betrayal was associated with increased MI shame, which was linked to more severe PTSS. Conversely, for those with high forgiveness, exposure to PMIE-Self and Other was associated with decreased MI shame and subsequently reduced PTSS. Conclusion: Dispositional forgiveness moderates the relationship between PMIE exposure and MI outcomes, particularly shame, which mediates the development of PTSS. These findings highlight forgiveness as a potential target for intervention in treating moral injury and preventing PTSS among combat veterans.