From our Moral Injury and Veterans Symposium in September 2015. Presented by Kathleen Pierce.

1. Moral Injury and Veteran
Suicides
University of San Francisco
September 15, 2015
Kathleen S. Pierce, PsyD
kathleen.pierce@va.gov
510-495-4450

2. Moral Injury: Definition
“The lasting psychological, biological,
spiritual, behavioral and social impact of
perpetuating, failing to prevent, or bearing
witness to acts that transgress deeply
held moral beliefs and expectations.”
Litz, Stein, Delany, Lebowitz, Nash, Silva
& Maguen 2009

3. A Military Definition of Moral
Injury
“A profound sense of alienation
and abject shame.”
Source: Battleland, Military Mental Health Ritchie,
2013

4. Pre-War Belief Systems
The world is benevolent
The world is safe
People are generally good
Bad things happen to bad people
People get what they deserve
If someone behaves badly, they should be punished
Witnessing of extreme human
suffering can call into question all of
these beliefs

5. Coming Home
Moral injury feeds on despair. When the narcotic
emotional intensity and tight camaraderie of war
are gone, withdrawal can be intense. As memory
and reflection deepen, negative self-judgments
can torment a soul for a lifetime. Moral injury
destroys meaning and forsakes noble cause. It
sinks warriors into state of silent, solitary
suffering, where bonds of intimacy and care
seem impossible. Its torments to the soul can
make death a mercy.
Soul Repair, Nakashima & Lettini, 2012

6. Readjustment Challenges
No longer have daily support of Military culture,
peers
Concerns about being judged by others
Resumption of civilian life, larger social values
Exposure to loved ones (spouse, children,
elders)

7. Internal Consequences of
Moral Injury
Feeling “broken” or “weak”
Concept of self as a monster
Extreme Guilt and Shame
Fundamental Mistrust –
Belief that the world is a dangerous place
People cannot be trusted or counted on
Belief that “I” cannot be trusted – a fundamental
shift in self perception

8. Guilt, Shame and Self
Condemnation are the
Hallmarks of Moral Injury
Guilt, Shame and Self
Condemnation are also
precipitating factors for
Suicide

9. Losing the Battle
The Challenge of Military Suicide
Center for New American Security
October, 2011, p3

10. Rates by Gender
Per 100,000
Men Women
Military 32.1 28.7
Civilian 20.9 5.2

11. PTSD & Suicide
Veterans with PTSD have a 6-10x greater
chance of committing suicide than U.S.
pop.
Panagioti , Gooding & Tarrier, 2009

12. PTSD & Suicide
Panagioti , Gooding & Tarrier, 2009
• VA reports 22 suicides per day among
the entire veteran population and 1,000
suicide attempts per month.
• Female veterans are 2-3x more likely
to commit suicide than nonveteran
women.

13. PTSD & Suicide
A Strong Relationship Exits:
PTSD alone = 6x risk of suicide compared with US
pop.
PTSD + Co-occurring disorder = 10x suicide rate
Combat
(or MST) PTSD
Substance Use
Depression
Available
Weapons
Highe
r
Suicid
e Risk
Panagioti , Gooding & Tarrier, 2009

14. Facts about Veteran
suicide
20 percent of U.S. deaths from suicide are Veterans (National Violent
Death Reporting System)
Veterans are more likely than the general population to use firearms as a
means for suicide (National Violent Death Reporting System)
Decreased suicide rates in Veterans aged 18-29 who use VA health care
services (National Violent Death Reporting System and VA Serious Mental
Illness Treatment Resource and Evaluation Center)
33 percent of recent Veteran suicides have a history of previous attempts
(VA National Suicide Prevention Coordinator reports, October 1, 2008 –
December 31, 2010 )

15. Resources
Veterans Crisis Line/Chat/Text
1-800-273-8255 and Press 1
http://www.veteranscrisisline.net/
Text to 838255
VA Suicide Prevention Coordinators
Each VA Medical Center has a suicide prevention
coordinator to make sure Veterans receive needed
counseling and services
Resource locator - http://www.veteranscrisisline.net/