I'm Not That Person: A Qualitative Study of Moral Injury in Forensic Psychiatric Patients

Abstract

Few studies have examined the psychological impacts of committing criminal acts of violence on the lives of perpetrators who were mentally ill at the time of offence and in which the act itself may reflect behaviour that is uncharacteristic of the individual. Theoretical and clinical reports describe a phenomenon termed moral injury which profiles the deleterious emotional effects that can arise from actions that transgress moral beliefs and expectations (Litz et al., 2009). Shame, guilt, spiritual/existential conflict, and loss of trust are considered to be core symptoms of moral injury (Jinkerson, 2016) with growing empirical studies which examine moral injury in military and public safety worker samples. The extent to which these kinds of moral injury phenomena might be evident among mentally ill perpetrators was explored using a qualitative-methods approach in a sample of 19 adult participants hospitalized in a forensic program inpatient service in Ontario, Canada. A qualitative interview was conducted where participants were asked to describe feelings about the index offence, the effect it has had on their well-being, and how they have coped with having committed the offence. We also collected quantitative measures of shame, guilt, psychopathology, and traumatic stress; findings indicated that the sample was demonstrating mean moderate levels of traumatic stress. Qualitatively, using a reflexive thematic analysis process, five themes and 23 subthemes were generated. Each theme relates to the various impacts, emotions, and cognitions experienced by the participants as a result of the index offence. The five themes which emerged were: (1) Living with the Emotional Aftermath; (2) Trying to Make Sense and Coming to Terms; (3) My Eyes Have Opened; (4) Facing the Music; and (5) Moving On. The findings are discussed in terms of their implications for understanding forensic inpatients who may be attempting to come to terms with offences they committed and for informing moral injury intervention strategies which might be adapted for the forensic mental health hospital service and recidivism prevention programs.