Values and Morals in Deployment – a Challenge for Mental Health

Soldiers and emergency responders – a special type of person?

Soldiers and emergency responders in the military, disaster relief services, police forces, fire departments and many other services are among the most valuable resources in society. They are on hand to help resolve a wide range of crisis and emergency situations at home and abroad, often at risk to their own health.

The people who work in these services – either professionally or on a voluntary basis – often have personal values that fit the typical needs of their roles. For example, they feel a special need to support other people, which goes hand-in-hand with a willingness to consistently put their own interests aside. In values research, this attitude is known as “benevolence” or “universalism”, but terms such as “rescue personality”, “compassion satisfaction” or “operators’ syndrome” are also commonly used in this context.^[1]

While these values are indispensable for the functioning of emergency services and ultimately for society as a whole, they create challenges for each individual that can affect mental stability and quality of life. They also form a significant basis for the development of moral injuries. Benevolence is expressed in many ways in the everyday lives of soldiers and emergency services personnel, for example in compassionate conversations with colleagues after difficult operations to show genuine empathetic interest, or also in a sense of camaraderie, which can motivate them to volunteer for an operation so as not to let colleagues or fellow soldiers down.

Such examples also demonstrate the Janus-faced nature of these values, however. When close colleagues who are experiencing stress are treated with empathetic sensitivity, this almost inevitably causes its own emotional distress, which in turn can add to the burden of processing an incident. And if a colleague or fellow soldier is injured during an operation, those involved often blame themselves for not having protected them sufficiently. This results in feelings of guilt, but can also pave the way for the development of psychological disorders.

After serving abroad in Kosovo or Afghanistan, around 130 members of the German armed forces underwent psychometric testing to assess their psychological stress levels. In line with what is stated above, the results showed a high average level of benevolence and, among particularly benevolent soldiers, a significantly higher incidence of symptoms associated with post-traumatic stress disorder (PTSD) and depression.^[2]

However, it would be premature to conclude from these findings that personnel who have this kind of personality structure should be protected by keeping them away from potentially traumatic deployment situations. Firstly, this would be at odds with effective deployment planning, as benevolence is usually associated with a particular altruistic motivation. Secondly, in many cases the persons concerned would perceive such a measure to be stigmatizing and ultimately reject it themselves.

It seems more appropriate to develop suitable preventive measures by both drawing on conventional trauma processing methods and raising awareness of approaches that consider values and moral conflicts. This will be discussed further below.

Changing values as a consequence of deployment

From a clinical therapist’s perspective – and this is supported by qualitative surveys conducted by the German armed forces – operational stress has the potential to cause a shift in personal values. There can be many reasons for this, ranging from extreme interpersonal experiences and disappointment with superiors, to intense intercultural contact.^[3]

Thomas Edward Lawrence, also known as Lawrence of Arabia, supported and led the uprising of Arab tribes against the Ottoman occupiers during the First World War. In his autobiographical novel Seven Pillars of Wisdom, which ranks as a work of world literature, he writes about the phenomenon of changing values. He describes a process whereby European values brought to a foreign cultural space – in this case Arabia – can become much stronger and more intense as a means of distinguishing oneself from the culture found there, and also as a way of securing one’s own psychological identity and stability. This change takes place as a kind of compensatory balancing movement.

He writes:

“Stokes the Englishman felt the Arab strangeness keenly and was driven to become more himself, more insular. He behaved with prefect manners, but with a shy correctness which reminded them [the Arabs] in every movement that he was unlike them and English. This careful consideration elicited a return of respect. [...] The other type [of Englishmen in the Middle East] was the John Bull of the book, who became the more rampantly English the longer and further he was away from England. In the end he invented an Old Country for himself, a home of all remembered virtues so splendid in the distance that when at length he did return he often found the reality a sad falling off, and often withdrew his muddle-headed self into a fractious advocate of the good old times.”^[4]

Such processes are not necessarily stressful or even pathological at first. They can reflect a healthy process of personality development and be experienced positively by the persons concerned, as a maturation process. However, it is also possible that the change in values leads to considerable inner psychological uncertainty and/or to interpersonal conflicts, especially upon returning to the familiar social environment.

For example, patients in a clinical setting regularly report that after experiencing an overseas deployment with the German armed forces, they developed particularly high expectations not just of their own performance, but also of integrity and correct behavior on the part of their fellow soldiers and superiors – because failure to live up to these expectations could have had serious or even fatal consequences in the field. In such situations, it can be difficult for soldiers to recognize that the current environment is now fundamentally different: while poor leadership is still considered unacceptable, its consequences are far less dramatic than they would be during deployment. The resulting emotional pressure is accordingly high and can manifest itself in aggressive conflict behavior, or feelings of disappointment, alienation or social withdrawal – people feel like “strangers in their own country” (to quote one patient). At this point, a potentially pathological level can be reached, especially if other symptoms or effects develop at the same time, such as post-traumatic stress disorder. It is not uncommon for both processes to interact with each other and create a fluid transition to moral injuries.

Moral injuries

This account of the role that personal values play for soldiers and emergency responders, and for adaptation processes in the context of deployment experiences, shows that the severity, frequency and clinical significance of value-related and moral conflicts tend to follow a continuum, rather than falling neatly into categories of “pathological” or “healthy”. Psychological reactions to morally relevant events do not only depend on the situational characteristics and personal perception of these events, but also on a variety of other, primarily individual factors – such as the structure of the personality or biographical history^[5]. To illustrate these connections, let’s take the example of a Bundeswehr deployment:

The severity, frequency and clinical significance of value-related and moral conflicts tend to follow a continuum, rather than falling neatly into categories of “pathological” or “healthy”

When a young soldier in a combat unit first goes abroad on an international crisis management mission, he has to adapt on a moral level; he experiences a moral challenge. Various aspects are involved, including his encounter with a cultural environment that is usually unfamiliar to him and whose customs and traditions are not like those of his own home country – such as, among other things, the culturally specific treatment of women and children. The challenge involves resolving any conflicts with his own values and embracing other values as an alternative way of living, possibly even as a chance for personal growth.

Stronger emotions and moral feelings, such as guilt, alienation, anger, grief or similar, then mark the boundary with moral stress, as these require active adaptation by the psyche in order to maintain mental stability – for example by talking to colleagues, chaplains or psychosocial helpers. They arise in morally questionable situations, especially when these persist over an extended period of time, in which those affected are aware of a morally correct course of action but are unable to implement it.

For example, a low standard of living in countries of deployment can pose a moral challenge. It may prompt reflections on priorities in life such as prosperity and security, resulting in greater satisfaction with living conditions in the home country. By contrast, the direct experience of severe child poverty could become a moral stressor – especially if, for example, the person concerned is unable to help and/or has children of their own. However, the boundaries between moral challenges and moral stress are fluid.

Similarly, the transition to a moral injury is not clearly definable. It depends to a large extent on the perceived psychological strain. Litz 2009 defines moral injury as experiences in which a person’s “deeply held moral beliefs and expectations” are shaken.^[6] In general, moral injury is associated not only with strong moral emotions, but also with increasing psychological symptoms. These can include anxiety, depression or addictive behavior, for example.

These connections illustrate the close link between values, moral conflicts and psychological disorders, and thus the high relevance to prevention and therapy in the context of the military and emergency services.

The distinction between direct psychological consequences of trauma and psychological reactions to moral conflicts is clinically important. As an initial approximation, it can be said that conventional psychotraumatology is based on the principle that the brain’s information processing capacity is overloaded with highly threatening, catastrophic stimuli, which leave behind reverberating memories, as in PTSD, or also fears.

By contrast, the focus when it comes to moral conflicts is on the cognitive and emotional processing of morally questionable behaviors or observations, which leave behind stressful or even pathological emotions such as sadness, alienation and possibly also guilt and anger. As with causes of trauma, a certain degree of objectivity and universal validity is expected in the assessment of potentially morally injurious events (PMIE).

However, there may be overlaps between the two areas, and they may also occur together. This is partly because many deployment or emergency situations involve traumatological and moral aspects. For example, if a servicewoman takes part in military combat operations, she is undoubtedly in a life-threatening situation, as she could be injured or killed. So the foundation for PTSD is in place. But if she is also actively involved in the fighting and injures or kills other people, she will have to ask herself afterwards whether she is guilty on a moral level. As a result of such overlaps, there are areas of symptoms that are difficult to distinguish from one another. For example, a flashback or involuntary recurrent memory after such combat action that repeatedly occurs in the form of vivid images (intrusions) or nightmares is very similar to an often equally intrusive rumination about moral aspects of fighting and killing, and how to deal with possible personal guilt.

The close links are also evident in the following epidemiological and empirical data:

• 40 to 60% of all American soldiers deployed overseas reported experiencing potentially morally injurious events.^[7]
• 25 to 34% of index events for combat-related PTSD in American studies were attributable to a situation that also constituted a moral injury.^[8]
• 21.4% of all German participants in an overseas deployment in Afghanistan in 2009/2010 subsequently suffered from a manifest psychological disorder, 2.9% of these from PTSD.^[9]
• Various studies have found significant correlations between moral injury (especially through one’s own actions) and PTSD, depression, suicide, anxiety, substance abuse (particularly alcohol), pain and sleep disturbances.^[10]
• Several personal values, including tradition, had a significant impact on the development of depression and burnout during an overseas deployment.^[11]

Preventive and therapeutic approaches

It is only in recent years that the armed forces of many countries, including Germany, have recognized the significance of moral conflicts and developed corresponding concepts for prevention and therapy. In the Bundeswehr, these concepts have been devised by a number of interdisciplinary working groups, each involving expertise in the areas of psychiatry, military chaplaincy, social science and psychology.^[12]

The content ranges from strengthening individual resources, such as social support, and raising awareness of the importance of personal values, especially benevolence and universalism (see above), to advice on dealing with moral injuries and their consequences (guilt, shame, anger, etc.) The way these topics are addressed is similar in preventive and therapeutic offerings, but there are differences in intensity. More detailed explanations are provided below in the section on the conceptual bases.

Case study

Key elements of these concepts will now be illustrated using an example of a typical sequence of deployment preparation and follow-up activities (the details have been compiled from several case studies, also for reasons of anonymity).

The combat soldier mentioned above – a lower-ranking soldier in his fifth year of service – is about two months away from the start of an overseas deployment. He first came into contact with the psychosocial field during his basic training. During this period, there were several training modules by the troop psychologist to raise awareness of inner psychological processes, as well as education by the military physician on the dangers of addiction, character guidance training on dealing with ethical issues by the military chaplain, and advice from the Bundeswehr social services department about social insurance in the armed forces.

The deployment region is likely to feature a cultural environment significantly different than that found in Germany, and various extreme psychological experiences can also be expected – such as combat operations, violent clashes among the local population, confrontation with poverty, etc.

For this reason, the battalion organizes several one-day prevention measures. The aim is for leadership personnel and soldiers who are likely to be particularly at risk to become familiarized with the expected psychological and moral conflict situations, and to teach simple exercises that can help reduce feelings of stress. These seminars are led jointly by the respective troop psychologist and the local military chaplaincy. Their content follows the “Handbook for the Primary and Secondary Prevention of Mission-Related Psychological Stress and Moral Conflicts”^[13].

During the mission, the soldier experiences various stressful events, including coming under small-arms fire and having to return fire. He also witnesses ethnic violence among the civilian population, and acts of violence against women and children. He frequently finds that his command center is overwhelmed and shows little concern for his unit.

In response to these circumstances, he has difficulty falling asleep and staying asleep, and experiences feelings of alienation and frustration. However, he does not seek psychosocial help, because initially he wants to fulfill his duties as best he can. He is worried that if he tells someone, he will be sent back home and let his comrades down.

Upon his return, he first spends a long vacation with his parents, siblings and their children, and gets involved with his soccer club. During this time, he feels mentally stable. Once he returns to his unit, however, his sleep disturbances worsen. In his dealings with his superiors, he frequently questions their orders, and he writes several complaints. He demands a lot of himself, works overtime, and takes on additional tasks.

In his free time, he avoids public transportation and markets because he feels unsafe there and has a vague feeling that something uncontrollable and threatening could happen. Loud noises, especially when they occur unexpectedly, make him feel as if he is back in the combat zone and he has flashbacks of combat situations, causing him to feel intense fear.

After several months, both his battalion counselor (a colleague who has had special psychosocial training) and his girlfriend tell him that his personality and behavior have changed significantly; he is no longer the same person that he was before his deployment. His girlfriend threatens to leave him if he does not seek help or treatment.

Because he wants to keep serving in the military, he does not go to his military physician at first. Instead, he sees a local social services employee. As part of her professional role, she explains to him that he may have a psychological disorder related to his deployment experiences, fills out a military service disability form with him, and sends it off.

She finally manages to convince him to see his military physician. The physician provides more in-depth psychoeducation on how to deal with his symptoms and reactions, also following the “Handbook for the Primary and Secondary Prevention of Mission-Related Psychological Stress and Moral Conflicts” mentioned above. Together with the soldier, the physician is able to draw on what the soldier learned in the period before his deployment and, for example, get him to agree to practice relaxation training from the website ptbs-hilfe.de. He also prescribes an antidepressant to improve sleep (Trimipramine 15 mg) and contacts the local military chaplaincy to discuss the apparent moral conflicts. Then he makes an appointment at the trauma outpatient unit of the nearby Bundeswehr hospital a fortnight later for further diagnosis and therapy planning.

In short, during the talk with the consultant there, several psychiatric symptoms are identified and diagnosed: PTSD, agoraphobia, and an adjustment disorder stemming from moral injury. The core symptom of PTSD is intrusive memories, meaning that the unprocessed traumatic events replay over and over again, sometimes in nightmares. Agoraphobia is a fear of public spaces, which is perceived as being unsafe in spite of the absence of any real threat. An adjustment disorder describes a change in inner mental experience due to external stressors (in this case moral conflicts caused by witnessing violence among the civilian population and the failings of the command center).

The patient’s fears of stigmatization are also discussed, focusing on the fear that the psychological disorder will disadvantage his career, which is what led him to delay starting therapy.

Due to the need for more intensive therapy and the conflicts in the unit, it is agreed to apply to the local social services for a transfer to a position outside the regular structures (known as admission to the protected period under the Act on the Continued Employment of Personnel Injured on Operations (Einsatz-Weiterverwendungsgesetz, EinsatzWVG)). This gives him the opportunity to work outside of his actual area of responsibility for an extended period, and thereby reduce the pressure to perform.

For therapy, he is recommended to start outpatient psychotherapy with a civilian psychotherapist near his home town. This should focus on dealing with everyday personal and work-related problems. In addition, if the therapist is qualified, specific trauma therapy for traumatic situations can also be provided on an outpatient basis. Alternatively, this can be done on an inpatient basis; this is possible both in the psychiatric departments of Bundeswehr hospitals and in civilian facilities. (Many soldiers prefer Bundeswehr hospitals because of the military and operational expertise available there.)

Inpatient interval therapy is arranged at the local Bundeswehr hospital, consisting of two to three inpatient therapy phases per year of three to six weeks each, in addition to outpatient psychotherapy. In between, a reduced workload of four hours per day is agreed as part of a structured reintegration program.

During the first therapeutic stay, two months after the initial consultation, the themes of psychological stabilization and structuring everyday life are explored in depth. This includes practicing stabilization techniques (for example, learning and applying relaxation training from the website ptbs-hilfe.de). An exercise program in the form of anxiety-related exposure is also started at the clinic, with the aim of continuing the exercises independently at home.

In the following treatment block, the threatening situations under fire are worked through using trauma therapy techniques, significantly reducing the frequency of intrusions.

Between the first and second blocks, the patient and his girlfriend also sign up for a weekend seminar for traumatized couples organized by the military chaplaincy’s ecumenical pastoral care project for people suffering from deployment- and service-related consequences (Arbeitsfeld Seelsorge für unter Einsatz- und Dienstfolgen leidende Menschen, ASEM), as well as for equine-assisted psychotherapy (EAP) at the Psychotrauma Center in Berlin.

After completing the trauma therapy treatment block, and approximately one year after starting psychotherapy, the patient takes part in group therapy at the Psychotrauma Center in Berlin, which focuses on values and moral conflicts. In a structured, semi-standardized program, an interdisciplinary team with psychiatric, pastoral and psychological expertise begins by looking at the significance of personal values in our everyday professional and private lives, and how values change in the context of a deployment. The focus then shifts to moral conflicts triggered by the behavior of others, as well as moral conflicts caused by one’s own behavior.

Over the course of the soldier’s treatment, there is a significant improvement in his psychological symptoms, and he is successfully reintegrated into regular service.

Conceptual bases

This program is comprised of various established components, with a focus on trauma, values, and morals. A selection of these are described briefly below by way of example.

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) involves a multimodal approach that addresses negative cognitions and feelings associated with trauma, including guilt and shame. Topics such as forgiveness^[14] and compassion^[15] are also included.

Acceptance and Commitment Therapy (ACT)^[16], strategic behavioral therapy^[17] and wisdom therapy^[18] are used to work on personal values in a psychotherapeutic context, for example.

Litz and his team were pioneers in the field of moral injury therapy with Adaptive Disclosure (AD), which involves, for example, engaging in imaginal dialogs with moral authorities.^[19] A similar methodological approach can be found in the U.S. Armed Forces’ Impact of Killing program^[20] and the eight-session group concept Building Spiritual Strength. The latter specifically addresses issues such as religious or spiritual stress and meaning making for female soldiers.^[21] On a more spiritually oriented level, spiritual/religious support offerings are also provided for people who have suffered moral injury.^[22]

Research has identified common factors that contribute to the effectiveness of these different approaches. Inner openness about moral conflicts, combined with a willingness to express them verbally, seems to account for some of the positive changes. It is also important to develop an attitude of forgiveness toward oneself and others.^[23]

The compilation and implementation of these elements for use in the German armed forces were manualized by the Psychotrauma Center^[24] and their effectiveness has been confirmed multiple times in controlled studies^[25].

Conclusion and summary

To sum up, experiencing traumatic events can be regarded as an essentially unavoidable part of the job description for soldiers and emergency responders. In many cases, these events also include aspects of moral injury that can shake the foundations of a person’s value system. For this reason, structured programs for dealing with post-traumatic disorders and moral conflicts have an increasingly recognized relevance in prevention, therapy and rehabilitation. Ideally, such programs should span the entire period of service and integrate the main psychosocial areas of expertise, in particular psychosocial medicine, pastoral care, social services and psychology. Exemplary concepts of this kind are already put into practice in U.S. American police departments.^[26]

Experiencing traumatic events can be regarded as an essentially unavoidable part of the job description for soldiers and emergency responders. In many cases, these events also include aspects of moral injury

With regard to psychotherapy for military and emergency services personnel who have a psychological disorder, group programs that focus on dealing with trauma and moral injury through interdisciplinary therapeutic teams have proven effective.

For successful implementation of such strategies in the respective systems, acceptance across all leadership and management levels is crucial.

DOI: 10.48701/opus4-820