Moral injury and seeking care: Why confidentiality matters
Some experiences from military service can be difficult to talk about, particularly when they may challenge deeply held beliefs about right and wrong.
We explored how perceptions of confidentiality may influence Veterans' willingness to seek support and discuss experiences related to moral injury.
Nazarov et al., Psychological Injury and Law, 2024
Why this question matters
Moral injury can arise when a person is affected by an experience that conflicts with deeply held moral values. Its impacts may include feelings of guilt, shame, anger, or betrayal, and can affect how someone views themselves and others. Moral injury and posttraumatic stress disorder (PTSD) can overlap, but they are not the same.
Discussing these experiences with a mental health professional may involve sharing sensitive details about events, circumstances, or decisions. People may understandably want to know how that information is protected, what the limits of confidentiality are, and whether there are situations in which it could be shared.
This led us to an important question: Could perceptions of confidentiality influence Veterans' willingness to seek mental health care, and what they feel comfortable sharing with a clinician?
[Veterans] weigh the possible repercussions, and they land on the side of saying nothing. That's a problem when one of the most important and consistent predictors of treatment success is being able to trust the clinician enough to share what you're thinking, feeling and experiencing.
How we investigated the question
In an online experiment, we asked Canadian Armed Forces Veterans to imagine seeking mental health care following hypothetical traumatic experiences. We compared scenarios involving potentially morally injurious events with conventional PTSD-related trauma, while also examining how responses differed by imagined military service status and descriptions of confidentiality.
who were Canadian Armed Forces Veterans.
were presented to participants, that varied in type of experience.
potentially morally injurious events
conventional PTSD-related trauma
We varied two conditions
for each hypothetical scenario.
Participants considered four questions
for each scenario, about seeking care, sharing details of the experience, and possible consequences of disclosure.
- 1
Seeking care
How likely would you be to seek mental health care?
- 2
Sharing experiences
How likely would you be to disclose details of the experience to a mental health professional?
- 3
Legal consequences
How serious would you consider the potential legal consequences of disclosing the experience?
- 4
Career consequences
How serious would you consider the potential career consequences of disclosing the experience?
Only asked for scenarios where the character is still serving.
What we found
Participants responded differently depending on the type of experience, whether they imagined themselves still serving, and how confidentiality was described.
Less willingness to seek care and share details
Compared with the PTSD-related comparison scenario, participants reported less willingness to seek mental health care or disclose details when imagining potentially morally injurious experiences.
Greater perceived legal and career consequences
Participants perceived more serious potential legal and career consequences when considering morally injurious experiences. Greater perceived career consequences were associated with less willingness to seek care and disclose details, while greater perceived legal consequences were associated with less willingness to disclose.
Confidentiality assurances made a difference
When imagining active service and a potentially morally injurious experience, participants reported greater willingness to seek care when confidentiality was clearly assured rather than uncertain.
How to apply this in practice
Clear information about confidentiality may help people make informed decisions about seeking mental health care and discussing sensitive experiences.
For Veterans & serving members
It's reasonable to have questions about confidentiality when seeking mental health support.
Ask your care provider what information is protected, what the limits are, and when information might need to be shared.
For Clinicians
Explain confidentiality protections and their limits early in the therapeutic relationship.
Invite questions and recognize that some patients may have particular concerns about discussing sensitive experiences.
For Policymakers & military leaders
Make confidentiality protections and reporting obligations clear, accessible, and consistently communicated.
Review whether existing policies and explanations are understood by the people they are intended to serve.
For Researchers
Further research can examine how these perceptions relate to actual treatment-seeking and disclosure, including among currently serving personnel.
Exploration is needed to understand whether clearer communication improves understanding, trust, and engagement in care.
How to Close the Trust Gap
We need to create a shared understanding to ensure that confidentiality protections are clear in practice, and trusted amongst those seeking care.
In doing so it may be possible to dispel stigma and create a safer place for those with moral injury to seek and benefit from treatment.
Read the full paper
Beliefs about confidentiality and attitudes toward disclosure of moral injuries among military personnel
- Authors
- A. Nazarov · C. A. Forchuk · W. A. Younger · R. A. Plouffe · C. Trahair · M. L. Roth · A. Tuka · Z. A. Shirazi · B. D. Davis · J. D. Richardson
- Journal
- Psychological Injury and Law, 2024
- DOI
- 10.1007/s12207-024-09521-8
Supplementary materials: Download study vignettes (PDF) ↓
Funding
This research was supported by Veterans Affairs Canada through the Veteran and Family Well-being Fund.