Socio-Cultural Perspectives in Moral Injury in the Military: A Nigerian Experience.

Brigadier General Gbenga Taiwo Okulate (rtd) *, Abdus-Salam Adeyemi, Dawuud ¹, Mojisola Bosede Akinsanmi ²

 

1. BSC Psychology, Psychologist, Counselling Department, Nigerian Armed Forces Resettlement Centre, Oshodi, Lagos, Nigeria.

2. B.Sc, M.Sc ( Psychology), Chief Clinical Psychologist, Department of Psychiatry, 68, Nigerian Army Reference Hospital, Yaba, Lagos, Nigeria.

*Correspondence to: Brigadier General Gbenga Taiwo Okulate, MBCHB, FWACP (Psychiatry), FMCPsych (Nigerian Army Medical Corps), Chief Consultant Psychiatrist, Department of Psychiatry, 68, Nigerian Army Reference Hospital, Yaba, Lagos, Nigeria.

Copyright

© 2023 Brigadier General Gbenga Taiwo Okulate. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 04 August 2023

Published: 15 August 2023

 

Abstract

It has been suggested that in future combats, combatants will more likely be confronted with morally injurious experiences than life-threatening predisposing stressors to 'pure' post-traumatic stress disorder (PTSD).  Morally injurious experiences include those acts of omission and commission that transgress an individual's fundamental values and long-acquired ethics. Since human responses to trauma are almost always partly culturally determined, it is quite likely that the symptom manifestations of Moral Injury and attempts to cope with them also have a strong socio-cultural connotation. The military, despite its strong ideology-based culture of toughness, togetherness and ‘strength in unity’, is often confronted with conflicting circumstances which potentially have moral, ethical and spiritual implications, especially during combat. Nigerian combatants are commonly inclined to adopt spiritual and religious techniques to militate against possible combat misfortunes. These methods are also naturally handy as coping methods against moral injury following combat. Unfortunately, public education in the military on the manifestations and management of moral injury, including getting those affected to seek effective intervention is often an uphill task. This is largely because of a military culture that stigmatizes and impacts negatively on veterans’ career if they report symptoms related to mental disorders generally, and moral injury specifically.

Keywords: moral injury; socio-cultural; military.

Introduction

Post-traumatic stress disorder (PTSD) as a diagnostic entity has evolved over the years and part of its evolution might have included recent effort to incorporate symptoms of Moral Injury (MI) into the PTSD diagnostic criteria in the fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association, DSM-V (American Psychiatric Association, 2013). The incorporation of some symptoms of MI into the PTSD syndrome has occurred despite some differences between the two. Moral injury was conceptualized as an experience of exposure to potentially morally injurious experiences (PMIE) and the unpleasant psychological consequences following such exposure (Jinkerson et al 2019). 

What constitute potentially morally injurious experiences (PMIE) may be likened to the Criterion A experiences of PTSD as outlined in the DSM-5. However, they include witnessing, failing to prevent, and perpetrating (alone or with others) acts which transgress one’s deeply held moral beliefs, values and expectations (Litz et al 2009), thereby creating a burden on the conscience. In the sense of violating one’s ethical expectations, they are different from the severe stressors or the repeated less severe stressors typically described in the Cluster A category of PTSD in DSM-5. In addition, they include ‘betrayal of what is right, by someone who holds a legitimate authority in high stakes situation’ (Shay, 1994), a situation which would ordinarily not be listed in Cluster A in DSM-V.

Cluster D category of PTSD criteria includes negative alterations in cognitions and mood symptoms that are of relevance to moral injury (American Psychiatric Association, 2013). These symptoms are guilt, self-blame and condemnation, anger and doubt related to faith, including cognitive distortion of betrayal by a supreme being. Also important would be the complications following these symptoms particularly suicide ideation and suicide. The socio-cultural components of these outcomes are understandably quite enormous.

The cultural determination of human responses to trauma, including morally injurious experiences is a large part of a society’s natural ways of expressing distress (Hinton and Lewis- Fernandez, 2011). It should therefore not be surprising that coping methods for addressing the manifestations of Moral Injury incorporate culture-based efforts for dealing with guilt and misplaced relationships, such as in individual’s faith and spiritual inclinations.

Moral Expectations

Moral and ethical values and expectations are usually deep rooted in religious and spiritual beliefs and according to Litz etal (2009) usually include 'culture-based, organizational and group-based rules about fairness and the value of life’. This concept appears to put an emphasis on specific socio-cultural factors playing dominant roles in the experience and manifestation of moral injury. This is relevant before, during and following exposure to potentially morally injurious experiences of combat. Religion and spirituality, (including a doubt in one’s faith or feeling betrayed by God) could become adaptive or maladaptive, depending on the circumstances of a combatant or an ex-combatant. In a highly religious society like Nigeria, it would be understandable if religion and spiritual issues need to be recognised and addressed in the military setting even when not reported by combatants because of inherent systemic barriers to seeking care.

In a previous report, (Okulate et al, 2021), we explained that in comparison to PTSD, little was understood by military mental health practitioners in our setting on moral injury and we suggested a need for further training for clinicians on the recognition and management of moral injury, including culture (and religion) sensitive perspectives following combat exposure.

In this report we aim to highlight socio-cultural factors in the development of moral ethics, generally and particularly in the military context and their implications in management of moral injury. The conflicts inherent in military values especially during combat and how such conflicts result in psychopathology will also be discussed. Interventions of socio-cultural relevance employed by individuals to obtain a relief from the burden of moral injury consequent upon exposure to battle will be explored. Finally, it is hoped that a full appreciation of socio-cultural factors in the military combat context should enhance planning relevant clinical, including culture-sensitive interventions for persons manifesting symptoms of Moral Injury.

Why is an Exploration of Socio-cultural Issues in Military Moral Injury Necessary?

To be clear, when potentially morally injurious experiences are encountered in all settings including after natural disasters, peace keeping, peace enforcement, counter-insurgency or conventional war operations, intense emotional experiences and reactions are expected to be encountered in all cultures, military and civilian. Some differences in patterns of emotional expression and healing attempts are also to be expected depending on the setting. Thus, although exposure to potentially morally injurious situations is part of the universal human experience, (for example, some health workers involve in triage in emergency and disaster situations could expect to experience some guilt after establishing treatment based on priorities), combat situations’ most unusual experiences place military service members at a heightened risk of moral conflicts and dilemma (Battles et al 2019, Dreschler et al 2011).

There are reports that service members are increasingly more likely to confront morally injurious experiences during deployment than life-threatening combat experiences (Hoge et al 2004). This has contributed to an increased interest in understanding the concept of moral distress and injury in serving military personnel and veterans. 

Societal Values, Individual Moral Codes and the Role of Law and Order

Most people begin to acquire moral values in their early life socialisation process during which complex processes become operative. The processes incorporate value introjection, modelling and reinforcements among others. Although largely acquired in family, school and other social settings, we suggested in a previous report (Okulate et al, 2021) that among Nigerians, a significant contribution to the development of individual moral codes emanated from early life and subsequent life-long exposure to religious teachings and indoctrination. As part of the shaping process to discourage undesirable behaviour, shaming as reinforcement method is not uncommonly employed in value acquisition process in almost all Nigerian cultures.

The emphasis on religious obligations has important implication when soldiers in combat are exposed to situations that are potentially morally injurious. It is noteworthy that value acquisition centred on religion and spirituality may be a phenomenon found in several other societies around the world. Fontana and Rosenheck (2004) suggested that among American veterans, a large proportion developed an understanding of ethics from religious teachings.

In essence, in all cultures, virtually anyone who violates previously acquired ‘set of codes’ and standards as they ‘navigate through life’ may be expected to experience feelings of shame and guilt (Litz et al 2009). In a Nigerian society where life-long exposure to religious indoctrination (with varying degrees of spirituality) is a common finding, as long as an individual has little or no loading for antisocial personality traits, it would be understandable if such an individual experiences a degree of guilt and shame following exposure to potentially morally injurious experiences. Combatants are not excluded, despite specific military training and orientation which are designed to ‘toughen’ them, enhance ‘esprit-de-corps’ and ensure success in combat.

Furthermore, it would be considered reasonable if they sought cultural and religion-based reparative interventions and behaviours following perpetrating and witnessing potentially morally injurious activities during combat.

Military Values, Code of Conduct and Moral Conflicts.

The military has well-entrenched values such as ‘destroying the enemy before they kill you’, but this indoctrination could be inherently conflicting considering deeply introjected values acquired by the combatants in their pre-military life. Some combatants do feel a ‘moral duty’ to avoid killing excessively or in unwarranted manners, again creating a conflicting situation. There are extant laws, values and ethics governing armed conflicts and peace-keeping operations, but these are sometimes impracticable or difficult to enforce especially during civil wars. These conflicting situations may contribute to emotional distress (de Graaf et al 2016). Thus, receiving adequate training on the implications of killing in combat does not totally eliminate the potential for experiencing moral aspects of combat trauma. (Dreschler et al 2011).

Two typical examples are where there has been an assault on one’s faith by comrades in battle and where there has been an assault on one’s faith by oneself.

A soldier, of deep Christian faith, reported poor sleep and wishing he had never returned from the ‘boko haram’ north –eastern Nigerian anti-insurgency operations. He had remained preoccupied with how he killed enemies in combat and how some of his colleagues who were fond of mutilating body parts of killed enemy soldiers were not listening to his intensely expressed objections. His suicide thoughts since he returned from combat had been unrelenting and on an occasion, he attempted to take an insecticide in a suicide bid. The symptoms became aggravated when his salary was stopped for reporting late to duty, followed by a superior cautioning him for being unlawfully bearded, an incidence he regarded as insensitivity and betrayal by superiors. He realized that he had become extremely touchy and wondered how he could be forgiven when he could not forgive others who had sinned. It was clear that his deeply introjected, religion-based conviction concerning spiritual aspects of the dead (and the essence of forgiving) had conflicted with the values of his colleagues on this matter and had thus become a moral injury issue.

Taking delight in undue punishment of prisoners of war and in mutilating the bodies of dead enemies are atrocities which have been found to have a powerful negative effect on mental health of surviving victims, the perpetrators and those who witnessed the events (Breslau et al 1991).

Assault on One’s Faith by Oneself

A soldier whose primary role on deployment was spiritual and welfare support to soldiers fighting the boko haram insurgency took on direct core armored and infantry roles following the death of a tank crew member. He belonged to one of the minority ethnic groups in Nigeria. He admitted to have killed excessively based on his deep seated resentment of another ethnic group who in combat were members of the Boko Haram insurgency. Alcohol and other substances had helped to numb any discomfort related to 'emotional killing'. They also provided agility and boldness to attack a highly determined enemy whose mission was mainly based on religious indoctrination. Having returned from combat, his alcohol drinking and smoking became accentuated. His colleagues, who appeared to tolerate his excessive atrocities in battle began to mock, criticize and ostracize him, thus worsening his guilt and shame. They mocked him at his fundamental level, jesting and enquiring from him if 'he was still a follower of Jesus Christ'. The rejection appeared to have exacerbated his loneliness, heavy drinking and suicidal thoughts. He refused further signing for rifles for some undisclosed reasons and requested to be transferred out of his unit, obviously concerned with shame and stigma and possibly to reduce access to weapon capable of being used for suicide. His attempt to address guilt included spending a lot more time in the church acting as an assistant, perhaps a form of undoing of some of the guilt burden. Put in another way, in defending against tormenting negative emotional consequences such as guilt, shame, anxiety, and difficulty forgiving oneself, it was clear that the ex-combatant was seeking relief using methods which were symbolically essentially ‘sin-atoning’.

Excessive or unjustified killing based on long-standing ethnic prejudice and using rape as a weapon of war or as a spoil of victory in battle appeared to be seriously moral injury experiences in the ex-combatant. Similar moral injury predisposing activities in combat provoking a profound sense of guilt could also include killing non-combatants in a mistaken belief that they are armed.

Unfortunately, guilt involving feeling bad about what one did to others and shame have been associated with suicide ideation among military personnel (Bryan et al 2013).

Military Hierarchy and Bonding Culture

Another consideration for predisposition to moral injury in the military socio-cultural context is the indoctrination binding on all members to ensure group success in peace and war at all cost. This is mainly attained through physical and mental toughness achieved from years of rigorous training, discipline, group bonding and group cohesion aided by trusted leadership. The military is often uncompromising on well understood hierarchy of command, channel of communication, and obedience to constituted authorities. However, aspects of this military indoctrination and training while often reducing the incidence of battle related physical and mental injuries may create dilemmas in taking decisions, a situation that often results in moral injury.

 

A Nigerian unit commander in combat, who headed a highly cohesive unit and was perceived by his subordinates as highly effective and reliable became deeply troubled by moral injury symptoms. He had had no choice but to obey a superior order to undertake an attack despite his (and his men’s) reservations about tactical, support and logistic considerations for the proposed attack. Convincing his troops of a ‘high likelihood’ of success of what he himself had his doubt about was the burden he found particularly regrettable. Unfortunately, the adventurous move resulted in a massive loss of his men and he felt personally responsible for persuading them to undertake a devastating attack. He felt he had betrayed his troops and felt guilty about accepting the superior order, although he admitted that he really had no choice. Feeling very guilty, he wished he could ‘explain things to those who had died that he did not wish to lead them to a death trap’. His guilt, shame and betrayal were intensified by telephone calls received from spouses of dead soldiers. For the commander, the transgressing morally injurious experiences had to do with a difficult decision he had to take, obeying orders that he had adjudged to be inappropriate. His widely acclaimed trusted leadership led to feeling of betrayal to others and consequent difficulty with self- forgiveness, a situation which he needed to seek spiritual intervention to address.

‘Broken bonds’

 Group bonding and cohesion entrench a profound attribute of ‘always being there for my colleague, in easy and difficult times’, but therein lies guilt and betrayal cognitions when a combatant is unable to evacuate a dying close colleague who has been injured in battle. Also, individual soldiers asked to be withdrawn from combat for whatever reason may quite feel a sense of betrayal of colleagues for ‘not being able to do my own part of the duty any longer’.

Unfortunately, as formidable as a military unit could be, there are many instants of disagreement between team members concerning the necessity or justification for killing an enemy. For example, there were several reports of persistent threats and loss of personnel caused by the enemy not engaging in conventional warfare but resorting to guerrilla tactics. Such experiences probably caused some combatants to become more aggressive than usual to civilians and even violate the rules of engagement (the case of an elderly lady described below illustrates this point). Those who found themselves powerless to influence the views of others witnessed helplessly as their colleagues killed such ‘civilians’ who they reasoned, could have been detained as prisoners but who their colleagues adjudged to be potentially dangerous. Witnessing such circumstances would have been a potential moral injury inducing situation needing special interventions. 

Role of Psychoactive Substances

Socio-cultural sentiments around alcohol use in many Nigerian societies, including the military is widespread. Off-duty alcohol use (and sometimes misuse) is somewhat widely assumed as promoting peer identification and support. However, instances where alcohol may have been used as self-therapy for guilt related negative emotions have not been uncommonly reported in our military clinical settings. This was evident in one of those cases described above.

In combat, widespread misuse of psychoactive substances to help with boldness and agility and a pervasive view that the ‘end justified the means’ as long as the mission objective to defeat the enemy was achieved, were factors that might have contributed to complicating the enforcement of rules of combat, thus directly and indirectly predisposing to moral injury. Under such circumstances, unauthorised killing might have escaped sanction with moral injury consequences on perpetrators and those who witnessed the acts but could not influence the phenomenon.

Unfortunately, a few of the perpetrators were previously ‘decent’ persons who had been repeatedly traumatised in battle and got ‘sucked’ into antisocial tendencies by the physical and mental complexities of combat. Such persons might have been at increased vulnerability to moral injury following combat.

The second individual described in this essay was generally regarded as a decent person whose role in combat was spiritual and welfare support to soldier until he took on direct core armored and infantry roles following the death of a tank crew member. The circumstances of combat made group enforcement of understood laws of combat difficult but on return, the group was quick to punish unacceptable behaviour that took place while in combat.

Socio-cultural Background and Rules of Engagement

Rules of engagement can sometimes limit involvement, although this is often the experience of soldiers in peace keeping operations. It is now clearly well established that despite the common co-occurrence of PTSD and moral injury, the symptoms of moral injury are less amenable to those therapies that are based on extinguishing conditioned fear and anxiety because the basic pre-condition for moral injury is not so much a threat to one’s life but one’s act of transgression that has shattered moral, and ethical expectations that are deep rooted (Maguen S & Litz B, 2010). Therapy may therefore need to involve spiritual and other forms of intervention to produce a long lasting effect.

Litz et al 2009, in their article on moral injury explained that ‘service members are often confronted with a lot of moral and ethical challenges in war. They may act in ways that transgress deeply held moral beliefs or may experience conflict about the unethical behaviours of others. Furthermore, warriors may also bear witness to intense human suffering and cruelty that shakes their core beliefs about humanity.

Conflict from witnessing human suffering even when one has not been a perpetrator of the suffering has also been recognised as a moral injury provoking situation. The socio-cultural context of the military creates a strong barrier to seeking help and attaining early recognition of post traumatic conditions. Obviously, not all who had been exposed to combat trauma would experience moral injury but we suspect that many who did would not express it for many reasons including the well-known barriers to seeking help. There is therefore a need to encourage early reporting.

Pre-deployment Factors of Socio-cultural Significance

A lack of trust in the leadership at any level quickly engendering conflicts is a major moral injury predisposing factor and almost always impacts negatively on the achievement of mission objectives. Commanders at all levels expect absolute commitment by all to group objectives in a war, but when some group members harbour doubts about how genuine the objectives are, conflict arises and a primary PMIE and MI symptoms often develop, particularly betrayal, anger and guilt.

Despite enlistment in the Nigerian armed forces being voluntary, poverty and youth unemployment are major driving motivations for enlisting into the non-officer corps. Also, the parts of Nigeria where insurgency and banditry flourish most are particularly deprived in educational and job opportunities for young persons. On this background, disaffection leading to moral issues of anger and betrayal on the part of persons who would have to or have had to engage in combat which they perceive as direct consequences of social neglect caused by others is often a consequence.  Similarly, a deep seated suspicion of possible economic benefit from the conflict by some powerful individuals in the political class may engender such cognitions and feelings. There are sometimes deep feelings of anger and betrayal expressed over adequacy of preparedness for aspects of combat. In clinical settings with soldiers just returning from combat, deep disappointment, anger and betrayal at various points in the military operations were commonly expressed. A similar phenomenon could occur among combatants in other societies.

For example, an ex-combatant encountered by one of the authors in a clinical setting in another country, whose role in combat on a second tour of duty was firing artillery in support of front fighters, expressed considerable concern and guilt that the shelling they had fired during combat would (preferred to say ‘would’ rather than ‘could’) have caused injury and death of some people. The ex-combatant  considered self as having been a party to a war which they considered to be ‘unwarranted and illegal’, feeling self-shame and guilt for being involved in action that harmed others but over which they did not have control.

Entrenchment of Moral Injury Symptoms          

Individuals who question the political or ideological reasons for war and in whom the conflict becomes a major potentially morally injurious experience, the death of colleagues with whom strong interpersonal relationships had been established over the years in the military bonding process may precipitate or deeply entrench moral injury symptoms. Similarly, providing medical care in combat under such circumstance may symbolically imply collusion with a ‘betraying’ higher military authority, laying a foundation for moral injury. Also, when confronted with a real threat to personal existence, it was understandable why some of the soldiers, for the first time, began to question the political and socio-economic motives behind the combat mission and why they as individuals were participants. Guilt and a sense of undeserving forgiveness may stem out of a feeling of ‘colluding’ with a falsification to justify a war. 

 

Spiritual Self-protection in Preparation for Combat

James Ramsay, a priest, explained a concept of faith in which pain, fear and death were embraced within an infinitely vaster continuum of grace, compassion and joy. He added that faith ensured that one entered a dangerous situation (in his case, anaesthesia and another dangerous procedure) in a state of great peace and awareness of love, ‘confident that whichever way the operation went, it was towards life’ (Ramsay 2021).  Such belief based on religion and faith might have led some soldiers to adopt some physical and mental injury-preventing activities when deployed to a setting with a definite threat to personal existence. Many Nigerian soldiers reported seeking spiritual protection but it was not clear how helpful this turned out to be in combat. The protections were commonly sought from traditional non-western practitioners and from Christian and Islamic faith practitioners. The phenomenon of seeking such intervention was commonly referred to in the local parlance as pre-deployment ‘cooking’. Many sought to get ‘cooked’ by wearing some form of spiritual preparations that were usually held in inner pockets while in battle. These preparations included, for example, wrapped up religious writings, traditional charms and photographs of a significant other. The holding of such objects might have offered a symbolic ‘protection’ and in effect probably promoted courage and self-caution in battle.  Where injuries occurred and they appeared ineffective, they could constitute a form of betrayal by a supreme being. On the other hand, if they seemed ‘protective’, they could result in a survivor’s guilt in circumstances where others died.

Not surprisingly, the phenomenon of seeking spiritual connection with supreme powers might not be peculiar to Nigerians. Many human beings have a need for connection with a supreme being especially when faced with grave situations which could potentially lead to death as in combat. Superstitious tendency, like other personality traits is present in all, albeit to varying degrees, but it is possible that they become magnified and find open expression when existence becomes threatened or potentially so, for example pre-deployment.

A combatant in another setting had expressed his disgust about having to deploy again mainly because he hated to have to pick up ‘bits and pieces’ of body parts of colleagues killed in action. He had continued to have re-experiences in his dreams and intrusive thoughts. Apparently, the avoidance of repeat exposures in battle outweighed the group loyalty that sometimes made military men feel they had betrayed their colleagues when for whatever reasons they could not immediately return to action. However, he blamed himself for the misfortune of colleagues that died. He gave a spiritual, somewhat magical perspective of why he did not die as he explained his manifestation of survivor’s guilt in the clinical setting. He had actually had several close shaves with death, for example he remembered having walked over an improvised explosive device and a short moment after him, a colleague walked over it and it detonated leading to his death. He attributed his escape to a ‘spiritual coin’ which his mother had given him before he proceeded on deployment and which he never took off his pocket. The ‘magical’ preservation of his life made possible by the metallic objects on him while several others died appeared to have contributed to his self-blame and survivors’ guilt and perhaps a disguised form of betrayal of ‘defenceless others’.

‘Culture Shock’ on the Battlefield.

A hallmark of military training and integration in Nigeria is the relative success in de-emphasising religious and ethnic differences among soldiers in various military locations. However, in carrying out the joint task of defeating the enemy, many soldiers become surprised at the intensity of pre-existing hostility between civilian ethnic groups in parts of the country not their own origin.

The insurgencies appeared to have resulted partly from years of inter-ethnic and inter-religious animosity and resentments which on deep investigation were sometimes perpetuated by local leaders. Again, it presents as deeply transgressing watching the level of brutality inflicted on an ‘enemy’ by combatants fighting on the ‘other side’ based on previously existing ethnic and religious resentments. This type of ‘culture shock’ may not be intensely different from the traumatic experiences of foreign peace keepers from a different culture as reported, for example, by veterans who got intensely shocked by the degree of brutality of one group over others in peace keeping operations, for example, in Bosnia.

Cross–cultural Differences in Experiences of Guilt.

As mentioned earlier, human responses to trauma, including those potentially moral injury predisposing have cultural determination. In reality, Nigeria is not a culturally homogenous entity and it is unpredictable to what extent guilt and shame cognitions are experienced by individuals from different Nigerian cultures in moral injury provoking circumstances. For example, if an individual had been socialised in a culture where violence against members of another ethnic group had been seen repeatedly as protective of one’s own ethnic group, then such violence might not have been discouraged. Such an individual might be expected to experience less mind injurious consequences following potentially mind injurious situations such as excessive killing, unwarranted killing and failure to discourage killing done by others.  Zefferman and Mathew 2020 also suggested that norms about killing opponents and civilians in combat vary between societies and the experience of depressive and guilt symptoms might therefore be influenced by combatants’ social and cultural context. They further added that individuals socialised in a community where a sharp distinction between military and civilian violence has not been seriously sanctioned from childhood, adults may experience greater moral ambiguity about killing in comparison to those who grew up in those societies that sanction subtle and real violent behaviours from childhood.

Another study conducted in an African setting reported that it was possible for perpetual violence to ‘immunise’ a person against the adverse effects of traumatic stressors, thus significantly reducing the risk of PTSD, with or without moral injury in the short or long term (Weierstall 2012). Some adults recruited into the Nigerian Army from areas where community violence from ethnic and religious violence had been long standing issues might be victims of this phenomenon.

Such individuals could have become highly ‘desensitized’ to consequences of moral injury-provoking behaviours. Thus, whether numbing of MI symptoms can be caused by repeated exposure to traumatic symptoms or not should be a subject for further research in our setting.

Socio-Cultural Considerations in the Management of Moral Injury:

Rebuilding Faith and Spirituality following Moral Injury

As explained, a doubt in one’s faith and a cognitive distortion of betrayal by a supreme being is central in the discomfort inherent in moral injury, justifying the need for spiritual based interventions. In our clinical experience, some of such strategies would sometimes have been embarked upon by individual combatants and veterans in an attempt to cope with tormenting negative emotional consequences such as guilt, shame, anxiety, and difficulty forgiving one-self and forgiving others. Adole et al (2015) reported that the most commonly used strategy in response to stressful situations by Nigerian soldiers was turning to religion. However, the self-undertaken therapeutic attempts, almost always require further intervention by others, usually Chaplains and Islamic priests. The interventions are, not surprisingly, essentially ‘sin-atoning’ and often include, cognitive restructuring surrounding forgiveness of self and others, including the use of specific forms of prayers and sacrifices, repeatedly done. Achieving healing through forgiveness entails rebuilding spiritual strength (Harris 2018) and spiritually integrated cognitive processing therapy (Held et al 2018, Pearce et al 2018). Purcell et al (2018) emphasized why the issue of forgiveness matters considerably to veterans who feel guilt and shame about their actions in war.

Rebuilding spiritual strength in our setting is practised by one of the authors who is an Islamic priest trained in mental health and extensively experienced in the management of post combat mental disorders. Such a person is generally perceived by others as being in a position of religious authority with ability to assist in addressing moral transgressions and guilt. The capability of supporting veterans to overcome symptoms of moral injury soon becomes a widely acclaimed attribute in the military location. Rebuilding spiritual strength essentially entails counselling, absolution, cleansing and forgiveness rituals with prayerfully instilled and reinforced knowledge of religious teachings (Pearce et al 2018) Sin atonement appears to be a fundamental issue in religion-based interventions.
 

‘Sin Atonement’

A combatant had been unable to handle persistently intrusive thoughts and the associated guilt, post combat, following his order to kill an elderly woman who was alleged to be an informant to insurgents, particularly when she audaciously refused to be relocated to a place of safety. A Muslim by faith, he had been in combat at various settings against insurgents and other terrorist bandits for many years. He had serious issues with seeking forgiveness from God for his ‘sins’. Initial therapy consisted of helping him to address his catastrophic thoughts by contextualising his extensive positive contributions in combat and to reflect on them. In subsequent therapy sessions, he began to recall more details of his positive contributions thus reflecting on them despite some of his ‘sins’. Implicit in the process is repeated exposure to his moral transgressing combat experiences, in expectation that his maladaptive thoughts and emotions would habituate eventually and be replaced by more adaptive ones. Home assignments included reference on relevant sections of the Holy Book and the repeated practice of some special prayers. Also part of the cognitive processing therapy was the deliberate introduction at intervals of issues related to hind-sighted self- blame (Held et al 2018) when in reality some of the decisions he took were inevitable to ensure group success in combat.

Suggestions to reduce Incidence of Moral Injury

Enforcing Laws of Armed Conflict

Extant laws that govern armed conflict in wars and peace keeping always exist but breakdown of law and order is very common during ethnic and religious combats. It would appear that strengthening these laws and their enforcement may prevent and even help to reduce post-combat consequences related to moral injury. For example, involvement in atrocities during war such as taking delight in undue punishment of prisoners of war and mutilating bodies of dead enemies could be discouraged using appropriate punishment.

Addressing Liberal Attitude to Alcohol and Substances in Combat

The issue of misuse of substances in combat will need to be recognised and addressed. Uncontrolled use of alcohol and other psychoactive substances to help, and implicitly approved, to achieve success in battle may lead to unauthorised killing with moral injury consequences on perpetrators and those who witness the acts but could not influence the situation. It may be a negative influence in implementing the extant laws that are relevant in armed conflict.

Addressing Military Cultural Barriers to Seeking Help – The Issue of Stigma.

Widespread education in military settings about moral injury manifestations and management is very central in addressing moral injury complications. However, stigma and prejudices have consistently created strong barriers in giving education and encouraging seeking care.

A well- recognised part of stigma is the tendency of soldiers, particularly the large number who have limited opportunity for other forms of employment after military disengagement to face difficulties reporting mental health problems worried about their military career being in jeopardy (Kessler et al 2005). Colleagues may alienate them, and family members may actively encourage them to seek more damaging procedures, some of which turn out to be further stigmatising traditional, non-orthodox treatments.  This often results in poor social support from the military and even from families, further aggravating mental health difficulties. This phenomenon needs to be addressed through education and the involvement of emotionally sensitive peers.

Inherent organizational obstacles are very formidable in the Nigerian military not just towards seeking mental health care but also towards mental health realities during educational campaigns. Many have difficulty contextualising moral injury in a supposedly hardened, well trained combatant, a situation which is a military cultural prejudice. These are issues that need to be overcome so as to encourage soldiers to seek help early when in distress.

Enhancing and Propagating Health Education

As noted previously, perhaps the greatest barrier to health education of military personnel especially the commanders lies paradoxically in military culture and indoctrination. Having undergone years of military grooming that emphasized peer support backed by effective leadership, it seemed inconceivable to be perceived as ‘weak’. Killing the enemy in battle, for example, is often rewarded and appears strange entertaining self-blame from such an action. However, the reality is that failure to recognise moral injury due to the burden of stigma can adversely affect overall mental health and may increase the risk of suicide (Koenig et al 2019).
 

Conclusion

For the average Nigerian, moral codes and ethical values have predominantly originated from life-long religious and other socio-cultural experiences. Military indoctrination and culture including activities on and off-duty put a lot of emphasis on team work, cohesion and well understood traditional values. Unfortunately, part of the indoctrination may be inherently conflicting in combat thus constituting potentially morally injurious circumstances. The rigidly entrenched chain of command, for example, makes refusing to carry out a morally transgressing act difficult.  Similarly, the ‘norm’ of ‘killing the enemy before they destroy you and your team’ is commonplace in battle but it is sometimes taken too far especially by individuals with ‘trait’ issues (for example, pre-existing antisocial personality traits) or ‘state’ issues, (for example anger and other forms of hyper-arousal symptoms of post- traumatic stress (Zefferman & Mathew 2020).

Many Nigerian combatants tend to use spiritual and religious techniques to militate against combat misfortunes, as well as coping skills against moral injury following combat. This may be understandable as shame and guilt following transgressions are significant parts of moral and religious introjections and attempt to address guilt is one of the major cornerstones of all religions

Thus, potential moral conflicts and dilemma occur at every point of military life particularly in combat. Failure to recognise moral injury because of the burden of stigma can adversely affect overall mental health and may increase the risk of suicide (Koenig et al 2019). Unfortunately, barriers to seeking help are abundant in the military and this tradition discourages appearing to be mentally unwell. A social liberal attitude to alcohol often seen as ‘promoting’ togetherness may be an unhealthy phenomenon as the disinhibitory effects of alcohol could be a factor in numbing previously well entrenched values particularly under the strain of battle.

There is a need to train more Chaplains and Imams on recognizing the symptoms of moral injury and employing appropriate spiritual methods for handling them. Spiritual interventions may from Chaplains, Imams and other traditional leaders to support healing, self and others’ forgiveness and effecting relationship repairs (Lindsay & Timothy 2018).

 Societal disintegration appears to be a major factor in social, religious and ethnic tensions resulting in violence, moral injury and their socio-cultural ramifications. There are issues in these regards that need to be carefully considered.

Currently, there is very little research being undertaken on spiritual management of MI. Indeed more will be required on risk factors for developing MI, culturally sensitive spiritual assessment tools, and ways to maximise the positive contributions of faith communities.

References

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