Is military training psychologically abusive

Changes in values ​​and moral injuries in the case of mentally ill soldiers in the Bundeswehr

Ten focus groups on value orientations and moral injuries were carried out with a total of 78 German ISAF soldiers who were in the Bundeswehr Hospital in Berlin for treatment for mental illness.

Diverse triggers and patterns of change and heterogeneous consequences were named, which indicated individual and only slightly stereotypical forms of reaction.

The topic should find its way into preventive and therapeutic concepts.

Keywords: German soldiers in action, value orientations, moral injuries, focus groups, mental illness.

Fig. 1: Dimensions of the psychological and moral change of operational soldiers

Summary

Deployed German Armed Forces soldiers are exposed to numerous traumatic events but also to situations with an impact on value orientations or equal to moral injuries.

Ten focus groups were performed in 78 German Armed Forces soldiers after deployment to Afghanistan who were treated in the Military Hospital in Berlin due to psychiatric disorders.

Numerous reasons and types of changes and also psychologic sequelae were reported, which pointed to rather individual and less stereotype reactions.

This topic should gain importance for preventive and therapeutic approaches in armed forces.

Keywords: deployed German soldiers, value orientations, moral injuries, focus groups, psychiatric disorders.

background

In 1992 the Bundeswehr set up a field hospital in Cambodia, where it provided medical care to both the international troops and the civilian population. For the first time since the end of the Second World War, German soldiers were active in a military operation outside the territory of the Federal Republic of Germany. This mission, as well as the subsequent missions in Somalia and Bosnia-Herzegovina, still represented peacekeeping mandates, on whose behalf the use of weapons was only intended for self-defense. This changed in 1999 with the international military intervention in Kosovo, in which the German side used armed force both in the air and on the ground.

This necessity then expanded significantly in Afghanistan from 2002, especially in the years 2009 to 2011 in the Kunduz area in northern Afghanistan. An epidemiological study by the Bundeswehr, which was carried out between 2010 and 2013 [1], provided empirical results for the first time on the type of stress and the corresponding psychological consequences. The events reported by the soldiers were very diverse. They mapped a spectrum that included an experience in a role as a victim of hostile acts as well as a “perpetrator” (in a non-legal sense), for example when participating in firefights. This significantly increased the risk of developing post-traumatic stress disorder (PTSD).

LITZ et al. [2] worked out that such experiences, but also other, maladaptive processes can be initiated. For example, there can be a dissonance with internalized values ​​and norms. This leads to moral evaluations, which can leave behind a moral injury (moral injury).

NASH et al. [3] differentiated between injuries caused by one's own actions and those for which moral authorities (such as superiors) are responsible. They converted these distinctions into a psychometric scale (Moral-Injury-Events - Scale). Moral injuries that are not dealt with can in turn contribute to phenomena such as feelings of guilt or shame, but also promote auto-destructive processes (such as addictive behavior or suicidality). These relationships have been examined particularly intensively in soldiers who were involved in the killing of people [4, 5, 6].

On the other hand, in connection with foreign assignments and the associated traumatogenic potential, positive psychological changes (such as growth and development processes) can also occur. TEDESCHI and CALHOUN [7] worked out the construct of "Posttraumatic Growth" for this purpose. This conception assumes that changes in experience and action can occur after the impact of trauma, which those affected perceive as enrichment. This includes an intensification of the appreciation of life, personal relationships and spiritual awareness, as well as an awareness of one's own strengths and the discovery of new possibilities.

As a necessary basis and an important influencing factor for the pathogenic and salutogenic processes described, various reference systems inherent in personality were examined, such as personality traits / disorders or individual value orientations. The latter represent conceptions of what is desired, which contribute significantly to the evaluation and control of behavioral options. On this basis, SCHWARTZ [8] developed a theory of human values ​​in which he initially defined ten types of values ​​that enable a comprehensive description of value-oriented experience and behavior. A typical feature of this theory is that opposing values ​​are also conceivable, such as the orientation towards material values ​​and pleasures (hedonism), opposed to altruistic, community-related values ​​(such as benevolence and universalism). These ideas led to the model of a circumplex arrangement of values.

SCHWARTZ summarized his theories in a questionnaire (Portrait Values ​​Questionnaire) [8]. Similar to the moral injury concept, connections between values ​​and mental health could be found on this basis, including in a military context [9].

Military missions abroad are particularly suitable for investigations and the formation of theories on the connections between moral injuries, value orientations and mental health, as this leads to definable extreme stresses that can change and impair value orientations and moral perceptions in a complex manner. However, quantitative research approaches seem to be only partially suitable for recording and describing this complexity, as they categorize and quantify moral experience, but under certain circumstances can only insufficiently take into account the interactions between the various influences, evaluations and processing processes.

So far, however, there are hardly any qualitative studies on this topic, especially in the military context. In addition, between the different nations involved in an operation, each with different cultural backgrounds and deployment scenarios with differing threats and intercultural experiences in the deployment country, considerable differences in the soldiers' response methods are to be expected.

The aim of this study is therefore to use a sample of in-patient psychiatric and psychotherapeutic treatment of Bundeswehr soldiers to describe qualitative relationships between moral injuries, value orientations, mental health and the associated coping processes in order to contribute to the formation of hypotheses and to formulate other necessary research priorities.

Methods

The evaluated data were obtained from ten focus groups with a total of 78 participants (six to nine participants per group). They were exclusively male Bundeswehr soldiers who had been on one or more missions abroad in Afghanistan as part of the ISAF mission. All participants were in inpatient treatment at the Bundeswehr Hospital (BwKrhs) in Berlin. The reason for this was an assignment-related mental illness. The average age was 34 +/- 9 years. 54 patients were diagnosed with PTSD, 29 with deployment-related depression, 28 with an adjustment disorder, 10 with somatoform and pain disorder, 12 with anxiety disorder, 13 with other mental illnesses (multiple answers were possible).

The focus groups were carried out at the beginning of a three-week group treatment, which is carried out in the BwKrhs Berlin three to four times a year to strengthen the resources of soldiers who have been traumatized. The groups had a therapeutic benefit that was in the foreground, as the results were used in addition to the scientific evaluation for further treatment planning. For this reason, no ethics vote was obtained.

Another inclusion criterion was the ability and willingness to talk about the subject of the investigation; Exclusion criterion was excessive subject-related emotional stress feared by the patient or determined by the interviewer in a preliminary discussion. The interviewers were in pairs and experienced in conducting focus groups. You had completed psychotherapy and trauma therapy training and several years of professional experience. The focus groups each lasted 90-120 minutes, were electronically recorded and verbatim transcribed.

The evaluation was based on content analysis according to MAYRING [10]; the interview guide was developed on the basis of a deductive category development. The theoretical models on which the initial hypotheses are based included the construct of personal value orientations according to SCHWARTZ, combined with quantitative studies on the Portrait Values ​​Questionnaire [8] and its associations with mission-related mental illnesses [9]. In addition, the construct of moral injuries (moral injury according to [3]) as well as the theories of LITZ [2] on the connections between moral injuries, guilt, shame and mental illnesses were included in the considerations. In the course of the study, inductive adaptations of the guideline were possible due to the emerging topics.

The interview guide contained the following overarching topics; The respective key questions are reproduced here:

  1. Were there any situations or circumstances during your assignment abroad that questioned your values ​​or offended your moral sense?
  2. Which of your personal value orientations have changed noticeably for you or your environment in the course of your assignment abroad and also in the time thereafter?
  3. What psychosocial consequences and physical or psychological symptoms are you related to the events mentioned while Noticed your assignment abroad?
  4. What psychosocial consequences and physical or psychological symptoms are you related to the stresses mentioned above to noticed the foreign assignment?
  5. What strategies have you used to cope with the aftermath of your experiences?

Results

In the group meetings that were carried out, there was always an open approach to the problem. The participants expressed themselves authentically and reported back after the focus groups that dealing with this topic was altogether new for them, but also helpful. The sometimes negative emotions (especially anger and disappointment) were easy to discuss and manageable.

Situations or circumstances in a foreign assignment that affect value orientations or have morally violated them

The group discussions usually began with the description of value-related significant or stressful experiences in the field.

Encounter with a foreign culture, shaped by different values ​​and norms;

  • Experience that traditions, customs and religion are valued by the local population;
  • Experience a cooperative and granting style of work at all levels within the military contingent (flat hierarchies, individual scope for decision-making);
  • Experiencing misconduct by superiors with negative or threatening consequences;
  • own misconduct with negative or threatening consequences.

The encounter with the culture of the country of assignment went hand in hand with intensive contact with different value and norm systems, depending on the respective activity. In negative terms, the treatment of individual social groups, especially women and children, was described as discriminatory or even violent: "Women and children are worthless there, they are treated like dirt and thrown away when they are no longer needed".

The differences could also be experienced positively: "A bottle of water is very valuable in the desert and I still find it difficult to just throw away water because I know how valuable it is down there. " In a broader sense, the topic of culture also includes dealing with traditions, customs and religion. The deep roots of the local population in these areas were often experienced by the participants as both impressive and too binding and therefore rather frightening.

With regard to military organizational structures and processes, around three quarters of the participants perceived the flat hierarchies within the deployment contingents as strengthening their own autonomy and their own scope for action. This led to an appreciation of one's own self-worth and contributed to the fact that the activities in the field could be rated with significantly higher meaning: “In action, we were all the same. We sat at the same table and talked at eye level. It's often different here at home. "

Various other aspects of the incident were experienced as decisive for one's own value orientations: The constant threat to one's own life and health led to a sometimes fearful uncertainty with regard to the matter of course for security and well-being. On the other hand, this experience also strengthened the appreciation and importance of health: “I could have died down there anytimecan. A.Today I think about death more often than before the mission, but I also look forward to it much more intensely every day. "

About a third of the respondents criticized the behavior of their superiors. Although there have been reports of exemplary behavior again and again, problematic aspects dominated. Superiors, who had been idealized in the domestic deployment preparation stage, were now experienced as overwhelmed. This was due, among other things, to orders that supposedly did not take sufficient account of the safety of subordinates: "They just send us out to investigate an IED (improvised explosive device), even though they knew it could go off at any time." In addition, there were allegations that superiors were too little interested in their subordinates and wanted to avoid mistakes for career reasons. But this also delayed important decisions. Support and recognition have been given too little.

But a discussion of one's own morally relevant misconduct was also discussed. The focus was on doubts about not having reacted or helped in various critical situations with sufficient professionalism or courage. This applied, for example, to the experience of poverty among the civilian population (especially among children), serious traffic accidents resulting in injuries or death, as well as acts of violence among the population: “We once witnessed an adulteress being stoned to death. We happened to be in a village, but we weren't allowed to prevent it in order not to provoke the village population. "

It was rated as particularly serious when there was a need to kill or injure people (around one fifth of the participants). Among other things, this resulted in internal conflicts with regard to humanitarian or Christian value orientations. It could be just as serious if killings could not be prevented (for example if comrades were shot or civilian victims of combat operations were also to be mourned): “Once the ANAs (Afghan Army) wiped out an entire village that was suspected to be the Taliban. We couldn't stop it. Afterwards I saw the many corpses. I had to throw up. "

Changes in value orientations through operational experiences

Three quarters of those questioned stated that personal value orientations had changed in the course of and as a result of their assignments abroad. Some of these changes were noticed by the soldiers themselves, and some only by those around them.

The following main categories were in the foreground:

  • declining value of material goods,
  • increasing importance of intangible goods,
  • Increasing importance of comradely relationships and obligations in business and family / friendly contacts in the private sector,
  • Greater care for comrades, especially during / from the mission,
  • greater care for the family,
  • increased importance of control, neatness and a sense of duty,
  • increased importance of sport as a source of self-esteem,
  • Developing or strengthening religious and / or ideological references,
  • Emphasis on hedonistic pleasure behavior.

Overall, there was a more emphatic - and possibly more uncompromising - attitude in the perception and representation of one's own value and norm systems.

Many soldiers reported that they went abroad with more material value orientations (for example, buying an expensive car from the foreign allowance), but had questioned its importance since the end of the foreign assignment. Instead, immaterial values ​​are now much more in the foreground, such as close contact with the primary family, the circle of friends, one's own family and also the regional origin. One participant stated: "Before, the only thing that was important to me was the car, after the outing it became clear to me how important my girlfriend is to me, and that has improved our relationship a lot.

This usually went hand in hand with the fact that the value of military comradeship increased significantly, and was associated with feeling more responsible towards comrades. On the one hand, this referred to comrades who were not yet operational and who wanted to be helped to be well trained and prepared. On the other hand, there was also an experience of obligation towards former combatants, sometimes for years, up to and including concrete assistance in emergencies. One combat troop soldier (Panzergrenadier) noted: “Since my comrades from Unit XY knocked me out, they have been very special people for me. I'll never forget that, they can come to me at any time. "

The more intensive family ties were expressed in some cases (around one tenth) as an increased need for control and security, especially with regard to their own children. This is perceived by the families as an over-control and restriction. One soldier reported that after the mission he only had to give his son instructions and not let him do anything on his own. This has already resulted in more disputes.

In three cases, participants reported seeking increasingly hedonistic pleasures: “I lived after the mission as if it were the last day. Sex, drugs, rock'n roll. "

Religious and ideological references also increased less often (about a tenth). About two-thirds of the soldiers, however, reported that they would represent their values ​​more emphatically and, under certain circumstances, more uncompromisingly. One transport soldier made the following comments: “I had to fight a lot in my mission. Any mistake could have cost me my life. Since then I have been reacting much more aggressively to mistakes my comrades make, because I know what can happen there. "

Psychosocial consequences and reactions due to changes in value orientations and operational experiences

In this area, the participants were able to determine consequences both during their deployment abroad and in the time after their return.

The consequences during the mission were:

  • Compassion for the suffering of the local civilian population / experiencing helplessness,
  • Need for help and commitment in aid projects,
  • Protection / defense against excessive emotional stress
  • Feeling of uselessness of commitment,
  • Anger at the local population,
  • Suspicion of new military personnel in the area of ​​operation.

Negative attitudes (especially anger and disappointment) towards the civilian population were reported by around half of the participants, occasionally coupled with feelings of shame about them. The reason was not infrequently the experienced or observed violence against comrades or local women and children. This anger was often expressed in derogatory terms for locals ("Klingons", "Knispel"). In addition, affects of anger and senselessness became clear when it was described that hostile forces (Taliban) were advancing from certain locations after the withdrawal of German troops and, for example, also occupied the former field camp in Feyzabad.

The opposite variant was a strong inner bond with the civilian population and their suffering. A soldier of the military police, who was often on the road in Afghanistan, reported: "After a while, I could no longer bear the misery. I joined the organization "Laugh / Help"[1] and was actually able to participate in some good projects. Among other things, we equipped a school with materials. That made me feel very good. "

Others stated that they had protected themselves from the high emotional stress of contact with the civilian population by avoiding encounters as much as possible.

Also to The foreign assignment showed various psychosocial consequences and reactions, some of which were difficult to distinguish in the group discussions from the symptoms of mental illness. One of the criteria discussed was which of the perceived changes were primarily due to value-related thought content.

The following were named in detail:

  • a more critical attitude towards superiors at home,
  • Aggressiveness and impatience towards comrades and superiors,
  • Experience of the mission as the only true reality, coupled with the desire to return there,
  • Proud of new experiences, feeling of superiority over comrades without commitment or over the German civilian population,
  • Alienation from the social structure of relationships at home,
  • general distrust or a feeling of not being understood,
  • Disappointment, bitterness, especially towards the Bundeswehr,
  • general feeling of tension,
  • somatoform symptoms.

A broadly identifiable basic attitude of the soldiers after foreign deployment was the perception of the deployment as “real life” despite all psychological and physical stress, combined with the desire to return to the deployment soon (“deployment junkies”). One combat troop soldier said: "Everything was so intense and so close to me, in comparison, life at home seems pale and artificial to me. I would like to go back immediately. " This was not infrequently combined with a feeling of alienation from the reference systems of the military unit and from friends and family after returning to Germany.

A considerably more critical attitude was then observed towards superiors: The reassignment into command hierarchies of the domestic routine, the experience of bureaucracy and similar elements led to considerable anger, especially if there was no operational experience with higher ranks: “I found my superiors, who weren't on duty, to be weaklings and no longer took them seriously. When they gave me orders, I usually carried them out, but then clearly expressed my reluctance. "

However, these processes of alienation were not always associated with negative feelings. There were also several cases that expressed a decided pride in their changes. This was based on having successfully mastered new challenges that do not occur in this way domestically.

At the symptom level, aggressiveness, mistrust, a feeling of lack of understanding, as well as disappointment and bitterness were named most frequently. The latter came into play particularly when recognition was rejected (e.g. damage to military service). One soldier who was deployed five times abroad described: “When the rejection of my military service damage came, I felt betrayed. I've been on a mission for my country so often, and then I'm not even symbolically recognized. "

In about a third of the respondents, somatoform symptoms also played a role, but they did not always reach the disorder level. The spectrum offered was diverse. In addition to unspecific vegetative symptoms, chronic pain was common. A striking example was a patient who had several healthy teeth extracted because of chronic jaw pain. Another example was a soldier who had gained around 50 kg in weight after the mission, which he attributed to "frustration eating".

Adaptive and mal-adaptive coping strategies

The described consequences of moral injuries and the change in value orientations led to various adaptive and maladaptive coping strategies in the soldiers concerned:

  • constructive, partly voluntary social engagement,
  • excessive social or health commitment,
  • shifted focus in life planning, for example with a desire to move closer to home,
  • Replacement / divorce from spouse,
  • Resignation and inner resignation,
  • increased need (affection / attention) with regression tendencies,
  • "Self-healing attempts" through abuse of addictive substances (especially alcohol),
  • lack of acceptance and resistance to therapeutic measures.

The disappointment that some soldiers felt when they were deployed by their superiors or the armed forces in general led in rare cases (around one fifth) to a feeling of resignation and internal dismissal. Those affected felt betrayed by the Bundeswehr and were no longer willing to invest more commitment than absolutely necessary in their official work. In part this was associated with long sick leave times, but in part also with increased substance abuse with recognizable auto-destructive tendencies. A combat troop soldier can be quoted as follows: “I used to be a very dedicated soldier. Today I don't really care about the Bundeswehr, it's just a job. I do the bare minimum, but I no longer enjoy it, I have no hope of change. "

Another group responded much more actively and externally: The Bundeswehr offers various secondary preventive preclinical aid measures for soldiers who were injured or were mentally disturbed. This group had already used measures of this kind several times and felt that they were exercising a right to which they were entitled. Occasionally (around a third) those affected also had a critical, sometimes demanding attitude towards the Bundeswehr with regard to medical care services. In some cases, these had already been the subject of petitions to the Defense Commissioner of the German Bundestag or led to accusatory reports in local and national media. Still others had sought contact with politics and stood up for the rights of disabled soldiers or showed volunteer work. This also included working in victim aid associations.

A reorientation in personal lifestyles was also a topic in the discussions. The aforementioned increased reference to family structures led to the desire to move closer to home in order to avoid weekend relationships (around a third of those surveyed). There was a high level of willingness to accept disadvantages in career development: “My family is now the most important thing to me. I used to always want to be a general, but now I don't care. I know what I have in my family and just want to be around them. "

But reactions to the contrary have also been reported. A relevant group (one third) of the respondents were already living in separation or divorce from their partner, mostly because the personal changes had led to an increasing distance in the partnership.

Conclusions

The aim of the present study was to use a qualitative survey methodology with focus groups to develop a differentiated picture of value orientations and moral injuries in connection with mission-related psychological stress and illnesses. The participants were surprised by the rapid development of cohesion and mutual understanding in the groups. These were also noticeable across different rank groups and educational levels and documented that value-related and moral aspects of the deployment apparently also have an integrating effect beyond social boundaries.

The overwhelming majority of the soldiers questioned had experienced morally injurious situations while on duty (moral injury). At the time of the survey, which was in some cases years after the events, these were still very much present and resulted in a wide range of reactions and changes. This included a change in personal value orientations, which included both positive and negative aspects for the soldiers, but not infrequently made it difficult to adapt to the social structures at home, both in the private and in the military environment. In addition, a close substantive connection between moral injuries and psychological stress or illnesses became clear again and again.

Stereotypical patterns that would generally indicate the connections between event, psychosocial reaction and possibly illness were not found. SUNDBERG [11] already pointed out that the individual interaction between an experienced military incident and the value system of the person concerned seems to be more decisive for the possible consequences than the incident itself.

On the other hand, various other military studies have also described associations that can be statistically mapped: The killing of opponents regularly led to an increased symptom severity of the post-traumatic stress disorder and also to depression, suicidality and addictive behavior [4, 5, 6]. In addition, connections between the frequency of participation in combat operations and the perpetration of atrocities or war crimes could be established [12]. The latter did not play a role in the sample surveyed here, which could have something to do with different application ranges, among other things.

In a survey of almost 200 German soldiers at the end of their deployment abroad in Afghanistan, connections were found between deployment experiences that primarily focused on dealing with the local population (such as acts of violence in the population, hostilities and the like), moral injuries and mental illnesses. According to the concept of moral injury according to Nash [3], the dominant type of these injuries was a serious deviation from moral principles by moral authorities such as superiors. This experience was in turn significantly associated with the severity of symptoms of post-traumatic stress disorder, depression and alcohol addiction [Hellenthal et al., Mission experiences, moral injuries, values ​​and mental illnesses among soldiers of the Bundeswehr, publication in preparation]

In two more recent studies on experienced German soldiers three to six months after the deployment, links between value orientations and psychological symptoms were found. Values ​​such as hedonism and stimulation were associated with a reduced frequency and severity of post-traumatic symptoms such as post-traumatic stress disorder, whereas universalism, tradition and benevolence apparently led to more serious illnesses [9].

Similar heterogeneous findings exist with regard to the change in value orientations through participation in foreign assignments. SUNDBERG [11] found no relevant changes in personal value orientations in 320 Swedish soldiers who were examined before and after a six-month foreign assignment in Afghanistan, as measured by the Portrait Values ​​Questionnaire. However, there was a significant correlation between participation in combat operations and the phenomenon of changing values, which, however, was only weak.

On the other hand, a study of young Israeli citizens in connection with the Lebanon war described more pronounced changes in values ​​[13]. BARDI [14] also showed connections between life events and the test-retest reliability of measuring instruments for value orientations that indicated an influence of external factors on values.

Another indication of changes in values ​​after the effects of the war was found in a study of 7,500 veterans of the Second World War carried out by WANSINK [15]. Veterans who were involved in heavy fighting during the war and assessed the war experience negatively, attended church institutions and events significantly more often than their comrades, who experienced the war more positively.

It is possible that the diversity of the findings also shows a difference between quantitative and qualitative survey methodology: Due to the instruments used, quantitative methods are subject to greater standardization, but also restrictions, and may therefore not be able to depict all aspects of complex causal relationships that are recorded in qualitative interviews can be.

A central element of the data presented here was, however, compatible with the existing literature: The described positive changes after the foreign assignment agreed in many points with the concept of post-traumatic growth according to TEDESCHI and CALHOUN [7]. This characterizes developments that can trigger a process of reflection and meaning in traumatized people. Parallels to the present study were particularly evident in the areas of intensifying the appreciation of life, personal relationships and becoming aware of one's own strengths.

Limitations
The informative value of this study is limited as the test subjects were selected from a clinical sample with pre-existing mental illnesses. This means that the results can only be transferred to a limited extent to all of the experienced soldiers. Another selection effect was that the opinion of those soldiers who were able to verbalize this difficult topic sufficiently was reproduced.

On the other hand, the various, very open statements created a differentiated overall picture, which presumably also depicts many areas of conflict for soldiers who are not sick after deployments abroad. To verify this hypothesis, focus groups should be carried out with soldiers who are mentally unaffected and with comparable key questions.

Methodologically, it was not infrequently difficult to relate the observed changes unequivocally to value orientations and moral injuries; this also applied to the clear differentiation between causes and consequences of these processes.

Conclusion

The results obtained within the scope of this qualitative study paint a differentiated picture of the changes and moral consequences of foreign missions among Bundeswehr soldiers and their connection with mental illness. Since moral injuries and a change in value orientations can evidently lead to considerable psychological distress or significantly intensify the influence of other stressors, these aspects of processing mission experiences should be given greater importance both in preventive mission preparation (“moral fitness”) and in therapeutic Find Bundeswehr Concepts. Initial approaches are already integrating moral injuries and the change in value orientations in therapeutic group concepts in German and American soldiers who have been traumatized by deployment [16]. An evaluation and expansion is planned.

central message

  • Mental illnesses in soldiers after deployments abroad are often associated with moral injuries and changes in value orientations.
  • Intercultural areas of conflict, but also problems within the contingent structures, are the trigger.
  • Psychological reactions can already occur during the deployment, but this usually happens afterwards.
  • Coping efforts of those affected are manifold and range from constructive growth processes to auto-destructive mechanisms.
  • The topic should find a significantly stronger entry into preventive and therapeutic concepts of the Bundeswehr.

literature

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Original work

Submitted: 04.10.2015

Revised version accepted: 20.10.2015

How to quote:

Zimmermann P, Fischer C, Lorenz S, Alliger-Horn C: Changes in values ​​and moral injuries in soldiers with mentally ill soldiers. Military Medical Monthly 2016; 60 (1): 7-14.

An English version of the text can be found here.
An English version of this article you will find here.


[1]
The association Lachen Helfen e. V. is an initiative of German soldiers and police officers for children in war and operational areas.

Date: 20.01.2016

Source: Military Medical Monthly 2016/1