‘I knew it was wrong the moment I got the order’: A narrative thematic analysis of moral injury in combat veterans
Open accessAbstract
OBJECTIVE: Moral injury is a nascent construct intended to capture reactions to events that violate deeply held beliefs and moral values. Although a model of moral injury has been proposed, many of the theoretical propositions of this model have yet to be systematically studied. METHOD: We conducted semistructured interviews with eight veterans who reported experiencing morally injurious events during war zone deployments. RESULTS: Using narrative thematic analysis, five main themes and associated subthemes emerged from the data. The main themes capture the timing of the event, contextual factors that affected the decision-making process during the morally injurious event, reactions to the moral injurious event, search for purpose and meaning, and opening up. CONCLUSION: The findings from the present study supported an existing model of moral injury, while extending it in several important ways. Preliminary clinical recommendations and directions for future research are discussed based on the study findings. These include directly exploring the context surrounding the morally injurious event, examining the veterans' moral appraisals, and helping them assume appropriate responsibility for their actions to reduce excessive self-blame. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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MI-related distress is sustained by maladaptive self-referential processing, including recurrent rumination, rigid moral self-appraisal, and self-condemning narratives.
“Recent empirical and theoretical literature suggests that MI-related distress is sustained by maladaptive self-referential processing—recurrent rumination, rigid moral self-appraisal, and self-condemning narratives that reorganize identity around perceived transgression or betrayal (8, 10, 15–18).”
From The therapeutic role of self-transcendence in moral injury recovery: theory, mechanisms, and clinical implications (2026) · cites this paper as [17]
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Cites
Narrative Methods for the Human Sciences
Riessman, C. K. (2007) · Cited by 5,251 · see citing works
FRANKL, V. E. (1946) · Cited by 3,910 · see citing works
Moral injury and moral repair in war veterans: A preliminary model and intervention strategy
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009) · Clinical Psychology Review · doi:10.1016/j.cpr.2009.07.003 · Cited by 2,738 · see citing works
Science of Science and Reflexivity
Bourdıeu, P. (2004) · Cited by 1,386 · see citing works
Psychometric Evaluation of the Moral Injury Events Scale
Nash, W. P., Carper, T. L. M., Mills, M. A., Au, T. M., Goldsmith, A. A., & Litz, B. T. (2013) · Military Medicine · doi:10.7205/milmed-d-13-00017 · Cited by 620 · see citing works
Achilles in Vietnam: Combat Trauma and the Undoing of Character
Shay, J. (2017) · The SHAFR Guide Online · doi:10.1163/2468-1733_shafr_sim170230057 · Cited by 609 · see citing works
An exploration of the viability and usefulness of the construct of moral injury in war veterans.
Drescher, K. D., Foy, D. W., Kelly, C. M., Leshner, A., Schutz, K., & Litz, B. T. (2011) · Traumatology An International Journal · doi:10.1177/1534765610395615 · Cited by 494 · see citing works
Delayed-Onset Posttraumatic Stress Disorder: A Systematic Review of the Evidence
Andrews, B., Brewin, C. R., Philpott, R., & Stewart, L. (2007) · American Journal of Psychiatry · doi:10.1176/appi.ajp.2007.06091491 · Cited by 444 · see citing works
Defining and assessing moral injury: A syndrome perspective
Jinkerson, J. D. (2016) · Traumatology · doi:10.1037/trm0000069 · Cited by 381 · see citing works
A Review of Research on Moral Injury in Combat Veterans
Frankfurt, S. B., & Frazier, P. A. (2016) · Military Psychology · doi:10.1037/mil0000132 · Cited by 316 · see citing works
The impact of reported direct and indirect killing on mental health symptoms in Iraq war veterans
Maguen, S., Lucenko, B. A., Reger, M. A., Gahm, G. A., Litz, B. T., Seal, K. H., Knight, S. J., & Marmar, C. R. (2010) · Journal of Traumatic Stress · doi:10.1002/jts.20434 · Cited by 310 · see citing works
Witvliet, C. V., Phipps, K. A., Feldman, M. E., & Beckham, J. C. (2004) · Journal of Traumatic Stress · doi:10.1023/b:jots.0000029270.47848.e5 · Cited by 262 · see citing works
Relationship of combat experiences to alcohol misuse among U.S. soldiers returning from the Iraq war
Wilk, J. E., Bliese, P. D., Kim, P. Y., Thomas, J. L., McGurk, D., & Hoge, C. W. (2010) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2009.12.003 · Cited by 260 · see citing works
Moral injury, meaning making, and mental health in returning veterans
Currier, J. M., Holland, J. M., & Malott, J. (2015) · Journal of Clinical Psychology · doi:10.1002/jclp.22134 · Cited by 257 · see citing works
Adaptive Disclosure: A New Treatment for Military Trauma, Loss, and Moral Injury
Litz, B. T., Lebowitz, L., Gray, M. J., & Nash, W. P. (2015) · Cited by 241 · see citing works
Farnsworth, J. K., Drescher, K. D., Nieuwsma, J. A., Walser, R. D., & Currier, J. M. (2014) · Review of General Psychology · doi:10.1037/gpr0000018 · Cited by 239 · see citing works
Wisco, B. E., Marx, B. P., May, C. L., Martini, B. L., Krystal, J. H., Southwick, S. M., & Pietrzak, R. H. (2017) · Depression and Anxiety · doi:10.1002/da.22614 · Cited by 222 · see citing works
A Scheme for Categorizing Traumatic Military Events
Stein, N. R., Mills, M. A., Hall, K. A. A., Mendoza, C., Borah, A. M., Resick, P. A., Litz, B. T., Belinfante, K., Borah, E. V., Cooney, J. A., et al. (2012) · Behavior Modification · doi:10.1177/0145445512446945 · Cited by 221 · see citing works
Jordan, A., Eisen, E., Bolton, E. E., Nash, W. P., & Litz, B. T. (2017) · Psychological Trauma Theory Research Practice and Policy · doi:10.1037/tra0000249 · Cited by 171 · see citing works
KILLING IN COMBAT MAY BE INDEPENDENTLY ASSOCIATED WITH SUICIDAL IDEATION
Maguen, S., Metzler, T. J., Bosch, J. O., Marmar, C. R., Knight, S. J., & Neylan, T. C. (2012) · Depression and Anxiety · doi:10.1002/da.21954 · Cited by 157 · see citing works
Smith, E. R., Duax, J. M., & Rauch, S. A. M. (2013) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2012.12.002 · Cited by 87 · see citing works
Held, P., Klassen, B. J., Brennan, M. B., & Zalta, A. K. (2018) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2017.09.003 · Cited by 82 · see citing works
Self-citationGalovski, T. E., Wachen, J. S., Chard, K. M., Monson, C. M., & Resick, P. A. (2015) · Springer eBooks · doi:10.1007/978-3-319-07109-1_10 · Cited by 77 · see citing works
A Narrative Framework for Understanding Experiences of People With Severe Mental Illnesses
Kirkpatrick, H. (2008) · Archives of Psychiatric Nursing · doi:10.1016/j.apnu.2007.12.002 · Cited by 70 · see citing works
How do morally injurious events occur? A qualitative analysis of perspectives of veterans with PTSD.
Currier, J. M., McCormick, W. H., & Drescher, K. D. (2015) · Traumatology An International Journal · doi:10.1037/trm0000027 · Cited by 66 · see citing works
Substance abuse, memory, and post-traumatic stress disorder
Tipps, M. E., Raybuck, J. D., & Lattal, K. M. (2013) · Neurobiology of Learning and Memory · doi:10.1016/j.nlm.2013.12.002 · Cited by 62 · see citing works
Narrative Methods in a Study of Trauma Recovery
Hall, J. M. (2011) · Qualitative Health Research · doi:10.1177/1049732310377181 · Cited by 62 · see citing works
Self-citationRamage, A. E., Litz, B. T., Resick, P. A., Woolsey, M. D., Dondanville, K. A., Young‐McCaughan, S., Borah, A. M., Borah, E. V., Peterson, A. L., & Fox, P. T. (2015) · Social Cognitive and Affective Neuroscience · doi:10.1093/scan/nsv102 · Cited by 35 · see citing works
Isolating effects of moral injury and low post-deployment support within the U.S. military
Houtsma, C., Khazem, L. R., Green, B. A., & Anestis, M. D. (2016) · Psychiatry Research · doi:10.1016/j.psychres.2016.11.031 · Cited by 28 · see citing works
Martin, R. L., Houtsma, C., Bryan, A. O., Bryan, C. J., Green, B. A., & Anestis, M. D. (2017) · Military Psychology · doi:10.1037/mil0000160 · Cited by 23 · see citing works
Wachen, J. S., Dondanville, K. A., & Resick, P. A. (2017) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2017.06.001 · Cited by 18 · see citing works
Narrative and Psychological Understanding
Josselson, R. (1995) · Psychiatry · doi:10.1080/00332747.1995.11024738 · Cited by 11 · see citing works
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Barnes, H. A., Hurley, R. A., & Taber, K. H. (2019) · The Journal of Neuropsychiatry and Clinical Neurosciences · doi:10.1176/appi.neuropsych.19020036 · Cited by 172 · see citing works
Defining Moral Injury Among Military Populations: A Systematic Review
Richardson, N. M., Lamson, A. L. S., Smith, M., Eagan, S. M., Zvonkovic, A., & Jensen, J. F. (2020) · Journal of Traumatic Stress · doi:10.1002/jts.22553 · Cited by 103 · see citing works
Heward, C., Li, W. W., Tie, Y. C., & Waterworth, P. (2024) · Military Medicine · doi:10.1093/milmed/usae276 · Cited by 66 · see citing works
Corona, C. D., Van Orden, K. A., Wisco, B. E., & Pietrzak, R. H. (2019) · Psychological Trauma: Theory, Research, Practice, and Policy · doi:10.1037/tra0000475 · Cited by 43 · see citing works
Frankfurt, S. B., DeBeer, B. B., Morissette, S. B., Kimbrel, N. A., Bash, H. A. J. L., & Meyer, E. C. (2018) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2018.00520 · Cited by 43 · see citing works
Effects of Resilience Strength Training on Constructs Associated with Moral Injury among Veterans
Barth, T. M., Lord, C. G., Thakkar, V. J., & Brock, R. N. (2020) · Journal of Veterans Studies · doi:10.21061/jvs.v6i2.199 · Cited by 41 · see citing works
Held, P., Klassen, B. J., Steigerwald, V. L., Smith, D. L., Bravo, K., Rozek, D. C., Horn, R. V., & Zalta, A. K. (2021) · European Journal of Psychotraumatology · doi:10.1080/20008198.2021.1877026 · Cited by 40 · see citing works
Self-citationKendall-Tackett, K., & Beck, C. T. (2022) · Frontiers in Global Women's Health · doi:10.3389/fgwh.2022.835811 · Cited by 34 · see citing works
Zasiekina, L., Кокун, О. М., Kozihora, M., Федотова, Т., Zhuravlova, O., & Bojko, M. J. (2022) · East European Journal of Psycholinguistics · doi:10.29038/eejpl.2022.9.1.zas · Cited by 32 · see citing works
Khan, T. H., MacEachen, E., Premji, S., & Neiterman, E. (2023) · BMC Public Health · doi:10.1186/s12889-023-15471-8 · Cited by 19 · see citing works
Houle, S. A., Colin, V., Jetly, R., & Ashbaugh, A. R. (2021) · Journal of Clinical Psychology · doi:10.1002/jclp.23205 · Cited by 20 · see citing works
Fleming, W. H. (2022) · Journal of Religion and Health · doi:10.1007/s10943-022-01676-5 · Cited by 16 · see citing works
Rodrigues, S., Mercier, J.-M., McCall, A., Nannarone, M., & Hosseiny, F. (2023) · European Journal of Psychotraumatology · doi:10.1080/20008066.2023.2205332 · Cited by 14 · see citing works
Zalta, A. K., & Held, P. (2020) · Journal of Traumatic Stress · doi:10.1002/jts.22516 · Cited by 13 · see citing works
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Jamieson, N., Usher, K. J., Ratnarajah, D., & Maple, M. J. (2021) · Journal of Veterans Studies · doi:10.21061/jvs.v7i1.214 · Cited by 10 · see citing works
Khan, T. H., & MacEachen, E. (2024) · BMC Public Health · doi:10.1186/s12889-024-18179-5 · Cited by 9 · see citing works
Emerging findings on trauma in the military.
Kendall-Tackett, K. A. (2019) · Psychological Trauma Theory Research Practice and Policy · doi:10.1037/tra0000459 · Cited by 9 · see citing works
Forkus, S. R., Schick, M. R., Goncharenko, S., Thomas, E. D., Contractor, A. A., & Weiss, N. H. (2021) · Military Psychology · doi:10.1080/08995605.2020.1842640 · Cited by 8 · see citing works
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Amir, D., & HaCohen, N. (2020) · International Journal of Applied Psychoanalytic Studies · doi:10.1002/aps.1649 · Cited by 8 · see citing works
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Hall, S. (2022) · Journal of Loss and Trauma · doi:10.1080/15325024.2022.2053227 · Cited by 6 · see citing works
Khan, T. H., & MacEachen, E. (2024) · PLoS ONE · doi:10.1371/journal.pone.0297770 · Cited by 5 · see citing works
Thomas, V., Bizumić, B., & Quinn, S. (2023) · doi:10.31219/osf.io/ht7ne · Cited by 5 · see citing works
ALTMAIER, E. M. (2019) · Elsevier eBooks · doi:10.1016/b978-0-12-811975-4.00001-0 · Cited by 4 · see citing works
Kanter, R. L., & Hassija, C. M. (2025) · Journal of Interpersonal Violence · doi:10.1177/08862605251315769 · Cited by 3 · see citing works
Houle, S. A., Inhaber, J., Jetly, R., & Ashbaugh, A. R. (2023) · Journal of Military Veteran and Family Health · doi:10.3138/jmvfh-2022-0057 · Cited by 3 · see citing works
Kiper, J. (2024) · Religions · doi:10.3390/rel15091089 · Cited by 2 · see citing works
Bowes, E., McAndrew, S., & Peach, D. (2023) · Pastoral Care in Education · doi:10.1080/02643944.2023.2271495 · Cited by 2 · see citing works
Thomas, E. D., Weiss, N. H., Forkus, S. R., & Contractor, A. A. (2024) · International Journal of Stress Management · doi:10.1037/str0000319 · Cited by 2 · see citing works
HaCohen, N., & Amir, D. (2024) · Frontiers in Psychology · doi:10.3389/fpsyg.2024.1286813 · Cited by 2 · see citing works
Symptoms of Moral Injury from a Psychological Perspective: A Systematic Review
Topçu, F., & Dinç, M. (2025) · Psikiyatride Guncel Yaklasimlar - Current Approaches in Psychiatry · doi:10.18863/pgy.1590616 · Cited by 1 · see citing works
Ridings, L. E., Held, P., Kuhn, E. R., & Stirman, S. W. (2026) · Journal of Traumatic Stress · doi:10.1002/jts.70092 · Cited by 1 · see citing works
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McCaslin, S. E., Bramlett, D., Juhasz, K. M., Mackintosh, M., & Springer, S. (2020) · Springer eBooks · doi:10.1007/978-3-030-32007-2_5 · Cited by 1 · see citing works
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Zimmermann, P. L., Willmund, G., Alliger‐Horn, C., & Rau, H. (2023) · Trauma und Gewalt · doi:10.21706/tg-17-4-312 · Cited by 1 · see citing works
Grimm, C. J., de Terte, I., Hodgetts, D., & Kearney, S. (2024) · Journal of Military Veteran and Family Health · doi:10.3138/jmvfh-2023-0086 · Cited by 1 · see citing works
Fleming, W. H. (2026) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2026.1701564
Bont, E. (2021) · Oxford University Press eBooks · doi:10.1093/med/9780198845706.003.0008
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Marima, R. E. E. (2021) · doi:10.51415/10321/4279
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Allen, S., Oxburgh, G. E., & Kiernan, M. D. (2023) · Journal of Veterans Studies · doi:10.21061/jvs.v9i1.402 · Cited by 1 · see citing works
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Laha‐Walsh, K., Steele, H., & Albright, D. L. (2023) · Oxford University Press eBooks · doi:10.1093/oso/9780197646588.003.0011
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Teck, T. S. (2025) · Journal of Academic Ethics · doi:10.1007/s10805-025-09672-6
Hutflies, T., Behnke, A., Zimmermann, P. L., & Spohrs, J. (2025) · Militär und Sozialwissenschaften · doi:10.1007/978-3-658-49207-6_16
Thomas, V., & Bizumić, B. (2025) · Springer eBooks · doi:10.1007/978-3-031-40858-8_320-1
Olenick, M., Clark, N., Thomas, K., Clements, P. T., Helmke, L., Khati, K., & Germaine, A. (2026) · Issues in Mental Health Nursing · doi:10.1080/01612840.2025.2596209
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Goris, J., & Johnson, J. (2026) · Bioethics · doi:10.1111/bioe.70128
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Meernik, J., DeMeritt, J. H. R., & Esparza, D. (2026) · Conflict Management and Peace Science · doi:10.1177/07388942261458245
Thomas, V., & Bizumić, B. (2026) · Springer eBooks · doi:10.1007/978-3-032-11375-7_320
Thompson, M. M., Granek, J. A., & Vartanian, O. A. (2026) · Frontiers in Public Health · doi:10.3389/fpubh.2026.1813972
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- Authors
- Held, P., Klassen, B. J., Hall, J. M., Friese, T. R., Bertsch-Gout, M. M., Zalta, A. K., & Pollack, M. H.
- Affiliations
- University of Tennessee at Knoxville (US)
- Rush University Medical Center (US)
- Venue
- Psychological Trauma: Theory, Research, Practice, and Policy
- Published
- 2019-05
- Volume
- 11
- Issue
- 4
- Pages
- 396-405
- ISSN
- 1942-9681 (ISSN-L)
- 1942-969X
- PMC
- PMC6215519
- OpenAlex
- W2802024423
- Cited by
- 52
- References
- 32
- Citations by year
- 2026: 8 · 2025: 6 · 2024: 7 · 2023: 9 · 2022: 5 · 2021: 6 · 2020: 5 · 2019: 5 · 2018: 1
- FWCI
- 4.99
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- Psychological Trauma Theory Research Practice and Policy (publishedVersion, other-oa)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- Cohn Family Foundation
- American Psychological Association
- National Institute of Mental Health (K23 MH103394)
- Brain and Behavior Foundation, and the Illinois Department
- Wounded Warrior Project
- National Institute of Health
- Edgemont Pharmaceuticals
- Jannsen
- Topics
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Life Sciences › Neuroscience › Cognitive Neuroscience › Psychology of Moral and Emotional Judgment
- Social Sciences › Psychology › Social Psychology › Emotions and Moral Behavior
- Keywords
- moral injury, combat veterans, moral judgment, self-blame, moral responsibility, meaning-making, moral values, military ethics
- MeSH terms
- War Exposure, Adaptation, Psychological, Adult, Alcoholism, Decision Making, Hierarchy, Social, Humans, Interviews as Topic, Male, Middle Aged, Morals, Stress, Psychological, Veterans, Narration
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