Conclusions: Theoretical Implications

The aim of this study was to advance the empirical and theoretical understanding of moral, political and societal dimensions of deployment-related moral distress, and thus contribute to the concept of moral injury and practical interventions to address and prevent moral distress. I achieved this by examining moral dimensions of experiences of distress, and the role of political practices and public perceptions in experiences of moral distress in Dutchbat and TFU veterans. In this chapter, I take stock of my findings, and discuss their implications for the concept of moral injury.

Main Research Findings

In order to be able to contribute to moral injury theory, I took a critical stance to the current concept of moral injury and any conceptualization of deployment-related suffering. To begin with, I explicitly distinguished between the concept and phenomena of moral injury (calling the first ‘moral injury’ and the second ‘moral distress’), thus refraining from reifying ‘moral injury’ as an objective thing. I found that although the concept of moral injury is explicitly intended to address moral aspects that the concept of PTSD fails to grasp, it focuses mainly on the ‘injury’ while attending too little to the ‘moral’. Also, as with the PTSD concept, it overlooks the wider context of deployment-related suffering. As my research focus, therefore, I chose the to-date insufficiently addressed moral and sociopolitical dimensions of moral distress, to advance the concept of moral injury.

In terms of research strategy, I adopted a qualitative, grounded theory approach, enabling me to inductively study phenomena about which existing theory is limited. My case studies focused not just on combat – the current focus of moral injury research – but also on peacekeeping. Specifically, I analyzed the Dutchbat and TFU missions, a ‘blue helmet’ UN peacekeeping mission met with harsh public criticism and a ‘green helmet’

NATO counterinsurgency mission that encountered mixed public response. I did not select a sample of veterans who matched the symptoms defined in the current concept of moral injury, but went for a more open, unspecified selection of veterans, including veterans with minor or no psychological problems at all. Finally, in analyzing the case studies, I went beyond the predominantly psychological perspective of the current concept of moral injury, and adopted a combination of psychological, philosophical, anthropological and political scientific perspectives. Together, this allowed me to examine experiences that overspill the boundaries of the current concept of moral injury and explore other than psychological interpretations for the experiences.

Taking the stories of 40 Dutchbat and 40 TFU veterans as starting points, I examined moral dimensions of experiences of distress, and the role of political practices and public perceptions in experiences of moral distress, during and after deployment. The veterans’

related their reasons for joining the military, their expectations of deployment, the reality of

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deployment, their experience of returning home, the distress that some developed, and how they responded to this distress. It became clear that when veterans struggled, their struggles were never confined to deployment, but also lay in the problems of resuming civilian life.

Specifically, many veterans related a post-deployment spiral of guilt and anger, leading to destructive and neglecting behavior toward themselves and their loved ones, increasing their guilt and anger, and so on. While each of the stories I heard proved to be unique, together they revealed insights into more than just the variety of veterans’ experiences.

They also showed patterns. These patterns included many parallels between the stories of Dutchbat and TFU veterans as well as between the stories of distressed and non-distressed veterans, while the differences between these groups turned out to be largely gradual, not fundamental. I analyzed the patterns and differences I found with the help of existing theory on trauma, morality and sociopolitical aspects of mental suffering, and information about the sociopolitical characteristics of the Dutchbat and TFU mission, which generated insights into how veterans’ stories related to their wider context. Chapters 5 to 8 presented my findings.

In Chapter 5, I focused on the stories of veterans who reported no or hardly any deployment-related distress, as well as on the ‘pre-distress’ memories of veterans who did eventually develop distress (both of which turned out to be very similar). Analyzing the stories, I tried to understand how soldiers perceive their profession in the first place and what cognitive strategies they tend to use to cope with moral challenges during and after deployment. This, in order to better understand why and when moral distress does arise.

The interviewed veterans’ accounts indicated that moral challenges often emerge in both

‘blue’ and ‘green’ operations. Also, their accounts showed that while the specific content of the cognitive strategies that soldiers use for moral challenges may vary, in essence they are remarkably similar. When experiencing moral tension, soldiers seem inclined, at least initially, to employ justifying simplifications to resolve the tension, relying on the belief that all situations are ultimately uncomplicated and soluble. For instance, faced with moral challenges on deployment, they may tell themselves that ‘some things just happen in war’, or they may employ formulas such as ‘I just have to follow orders’, ‘it was him or me’ or ‘I treat them as they treat me’. Also, to resolve possible tensions arising from being both a soldier and a civilian, they may compartmentalize their military and civilian selves, prioritizing the former in military contexts and allowing the latter to supersede in others. The veterans’

stories showed that soldiers may interpret the compartmentalization they employ, of which they are often aware, as the necessary burden required by their profession, which allowed them to interpret soldiering as morally right not in spite of the fact that they are civilians too, but because of it.

Simplification and compartmentalization appeared in virtually all veterans’ stories, distressed or not. Yet, the stories showed that these strategies can fail. In Chapter 6, I examined the specific moral dimension of moral distress, honing in on the stories of veterans who reported moral distress. In examining this dimension, it became evident that the moral complexity of particular quandaries cannot always be simplified and that particular actions cannot always be unequivocally justified or excused. These actions were condemned. Yet, just as veterans were unable to unequivocally justify or excuse these actions,

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they usually could not unequivocally condemn them. When the interviewed veterans related morally distressing experiences, their stories spoke of value conflicts in which adhering to one value inevitably means violating another, of moral detachment resulting from the overwhelming significance of a situation, and of senselessness. These situations did not involve straightforward moral transgressions (the focus of current studies on ‘moral injury’), and thus do not allow clear-cut interpretations (which soldiers tend to employ). While many veterans blamed themselves or others for these situations, they often felt uncertainty and conflict with respect to judgments. That is, besides guilt, shame and anger, morally distressing events often engendered a profound sense of moral disorientation. Many veterans lost their trust not only in the goodness of both themselves and the world, but also in the very notion of good and bad. This painful loss forced them to engage in an ethical struggle against previous moral expectations and beliefs, in the attempt to resolve the arising moral questions and find moral re-orientation again.

Besides moral distress at the individual level, I examined the role of political practices in moral distress in Chapter 7. Specifically, I examined whether and how political decision-making and framing surrounding military missions contributes to the emergence of particular morally distressing experiences for soldiers ‘on the ground’, both during and after deployment. While virtually all the interviewed veterans spoke about how political practices had adversely affected their deployment, it was the veterans who related facing disturbing situations due to political practices who spoke about how political failures had wrapped their mission in pain. Remarkably, although the Dutchbat mission was a peace mission while TFU’s mission was a counterinsurgency mission involving combat, comparing their stories revealed striking similarities. Both groups related similar themes of powerlessness, senselessness and abandonment both during and after their mission. Further analysis showed that these similarities were related to the fact that on the political level, too, the missions had far more in common than expected. To be sure, compared to the Dutchbat mission, the TFU mission had a clearer mandate, more resources available and an improved mental health care system. However, at a more fundamental level, the two missions were characterized by similar unresolved conflicts, including discrepancies in the why (overarching purpose), what (objectives) and how (resources and possibilities) of the mission, ambiguity regarding the why, what and how of the mission, discrepancies between soldiers’ operational experience and political narratives, and lack of political acknowledgment of such issues and thus of the role of political practices in distressing experiences. As became evident, political compromises do not always mean that problems are solved. On the contrary, rather than achieving true reconciliation of conflicting views and interests, compromises may mean that conflicts are left to lower levels to deal with. As a result, veterans’ stories showed, soldiers may develop profound feelings of political betrayal and, in turn, seek symbolic and material reparations from the political leadership, for instance by filing a lawsuit against the state to enforce apologies and compensation.

Finally, in Chapter 8, I examined the role of public perceptions of military missions and the military in general in experiences of moral distress. Dutchbat veterans faced harsh criticism, while the TFU mission evoked both negative and positive reactions. Despite the different public responses, the two groups had striking parallels, as was the case with respect

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to political practices. While the Dutchbat veterans interviewed generally reported a stronger sense of frustration about Dutch public perceptions than the TFU veterans did, both groups spoke of anger, silence, disorientation and estrangement in relation to the Dutch public. My findings showed that veterans perceived both public criticism and admiration as simplistic distortions that did injustice to their deployment experience. The greater the distress with which veterans struggled due to their deployment experiences, the more they were usually affected by public perceptions. While their experience may in part be explained in terms of misguided fears and judgments on their part, it also turned out that in both missions public narratives did indeed convey rather one-dimensional images of perpetrator and victim, normal and abnormal, and good and evil, which stood in stark contrast to veterans’ personal experience. Many veterans experienced this one-dimensionality as societal misrecognition of their deployment experiences, which particularly affected the veterans struggling with their experiences, leading to a sense of estrangement among them. In fact, this experience of societal misrecognition often engendered not only a sense of estrangement from society, but also from themselves.

Refining the Concept of Moral Injury

Drawing my research findings together and juxtaposing them with the current concept of moral injury, the following conclusions emerge (see Table 4). In line with the current concept (Litz et al. 2009, 2015, Nash and Litz 2013), my findings indicate that the feelings of guilt, shame and anger with which veterans may struggle require an approach that takes these feelings seriously. Veterans’ moral emotions and judgments cannot simply be lumped together under the umbrella of subjective experience, if only because they may need different responses. The veteran who blames himself for having survived an attack while his colleague died might be helped most by having his thoughts challenged and his feelings of guilt alleviated, whereas the veteran who feels guilt for having actively hurt other people may instead find meaning most in having his sense of accountability confirmed and self-forgiveness. In other words, veterans’ moral distress should not be readily explained away as misguided, but requires considering their moral judgments and emotions as possibly appropriate. This is in line with the current moral injury concept.

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Table 4: The Current and a Refined Conceptualization of ‘Moral Injury’

° Ambiguity regarding the why, what and/or how of the mission

Yet, my study also yielded insights different than found in other research on moral injury.

Confirming existent philosophical and social scientific theory on morality, it showed that a person’s moral beliefs are not a coherent system, as the current concept of moral injury implies, but a complex constellation. Soldiers are both instrument and agent, civilian and soldier, and their multiple roles come with potentially competing moral requirements. My research showed that while soldiers are generally able to resolve minor conflicts between competing moral requirements by means of strategies of simplification and compartmentalization, these strategies may fail in the case of more severe conflicts, with particular implications.

My findings demonstrated that ‘morally injurious’ situations may involve more ambiguous and ambivalent experiences than unequivocal transgression, which, moreover, may have important sociopolitical aspects. I often found that veterans paradoxically feel both guilty and non-guilty, both responsible for their own acts and betrayed by the political leadership, both misrecognized by societal simplifications and rightly judged by society for their actions. Fundamentally, they may feel they failed morally but at the same time develop the sense that their moral beliefs and expectations failed them. As is the case for unequivocal emotions and judgments, paradoxical feelings cannot be readily interpreted as misguided.

Rather, they should be understood as the result of the moral complexity of the situations veterans encountered.

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In line with this moral complexity, my findings showed that moral distress may involve more than the guilt, shame and anger emphasized in the current concept of moral injury. Veterans may also experience the complex emotion of tragic-remorse, which is remorse about the fact that the morally best option in this situation was merely the lesser evil, and they may feel moral disorientation, which is the loss of previous certainties about wrong and right, thus a loss of the moral frame of reference and perhaps also of the moral self-perception. In addition, when veterans perceive distressing experiences as partially caused by the wrongdoing of others, they may develop a sense of betrayal, including violated trust and dependency. Perceived societal misrecognition of the experiences with which they struggle, moreover, may engender anger while at the same time amplifying or even causing self-doubt. In turn, veterans may develop a sense of estrangement from both society and themselves, involving both the feeling of being cut off from society and the sense of being removed from oneself.

Such experiences may provoke a variety of behavioral responses. As indicated in existing research on moral injury, this includes self-handicapping and self-injury behavior (Frankfurt and Frazier 2016). Additionally, my research showed that veterans may engage in an ethical struggle with previous moral expectations and beliefs. And they may seek political reparation, demanding political amends and financial or symbolic compensation. Further, they may seek societal recognition, specifically societal justice for their experiences.

Regarding types of potentially morally distressing events, the current concept of moral injury acknowledges that not just acts of commission (e.g. killing) but acts of omission (failing to prevent human suffering) may also engender moral distress. Nevertheless, the literature on moral injury focuses almost exclusively on conventional war and combat situations, particularly the impact of killing (see e.g. Bica 1999, Litz et al. 2009, Drescher et al. 2011, Brock and Lettini 2012). In the two missions I examined, however, by far the most reported distressing experience was not active infliction of harm, but inability to act in the face of human suffering. The potential of non-action being morally distressing, thus, should also be taken into account.

With respect to factors other than the event, the current concept of moral injury points to the basic human assumption that the self and the world are good and meaningful (Litz et al. 2009, Nash and Litz 2013). My findings indicated that beliefs about the self and the world as logical, coherent and fair may also play an important role in moral distress, potentially engendering profound moral disorientation when veterans are confronted by events that testify that the self and the world are utterly illogical, incoherent and unfair. The same goes for other beliefs, such as the military ‘can-do’ attitude which considers doubts, conflict and uncertainty bad things.

Besides personal beliefs, my research indicated, contextual factors such as political practices and public perceptions often play an important role in moral distress. While I described veterans’ experience in terms of perceived political betrayal and societal misrecognition, I also maintain that these themes are more than a matter of subjective experience. This is in line with epistemological foundations of this study, which involve an approach to human experience in terms of meaning-making processes while appreciating that people’s experiences are not just intra-psychic processes but also informed by contextual factors. Building on these crucial insights, I analyzed veterans’ stories in relation to existing

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literature on the Dutchbat and TFU missions, and this led me to argue that just as veterans’

own agency in their suffering should be considered, the role of sociopolitical factors should be taken seriously.

Regarding political factors, it became clear that as political decisions and narratives move down the chain of command, they affect soldiers at the micro-level. While conventional ‘green helmet’ war operations increase the risk of soldiers developing moral distress because of their active use of violence, ‘blue helmet’ peace operations increase the risk of moral distress related to failure to act. Most importantly, perhaps, is the extent to which a mission’s character matches or conflicts with operational reality. The Dutchbat mission, for instance, was a peacekeeping operation to a war area where there was little peace to keep, and consequently created morally critical situations for Dutchbat soldiers on a daily basis. In relation to this, the specific ways in which competing political and public perspectives and interests surrounding a mission are dealt with are relevant. For instance, if restrictions are imposed on a ‘green helmet’ mission in response to political and public objections, as was the case in the TFU mission, soldiers can feel helpless in the same way that ‘blue helmet’ peacekeepers can feel. The other way around, if soldiers are asked to use robust force in a mission that is supposed to center on humanitarian acts, they may come to regret their actions in retrospect. Generally, discrepancies and ambiguities in the why, what and how of a mission, and lack of political acknowledgment of such discrepancies and ambiguities seem to increase the risk of soldiers developing feelings of

Regarding political factors, it became clear that as political decisions and narratives move down the chain of command, they affect soldiers at the micro-level. While conventional ‘green helmet’ war operations increase the risk of soldiers developing moral distress because of their active use of violence, ‘blue helmet’ peace operations increase the risk of moral distress related to failure to act. Most importantly, perhaps, is the extent to which a mission’s character matches or conflicts with operational reality. The Dutchbat mission, for instance, was a peacekeeping operation to a war area where there was little peace to keep, and consequently created morally critical situations for Dutchbat soldiers on a daily basis. In relation to this, the specific ways in which competing political and public perspectives and interests surrounding a mission are dealt with are relevant. For instance, if restrictions are imposed on a ‘green helmet’ mission in response to political and public objections, as was the case in the TFU mission, soldiers can feel helpless in the same way that ‘blue helmet’ peacekeepers can feel. The other way around, if soldiers are asked to use robust force in a mission that is supposed to center on humanitarian acts, they may come to regret their actions in retrospect. Generally, discrepancies and ambiguities in the why, what and how of a mission, and lack of political acknowledgment of such discrepancies and ambiguities seem to increase the risk of soldiers developing feelings of