Sweden has been an active participant in the international military scene for more than a half-century. Swedish military personnel have been sent out in many of the intervention paradigms of the latter half of the 20th century and the early 21st century war on terrorism: to Congo, Sinai, Lebanon, the former Yugoslavia, Afghanistan and Mali, to name a few. From 1953 on, 67,093 Swedes have served on international military missions. According to information from the Swedish Tax Agency, 54,218 of these veterans of foreign conflicts were alive in September 2021. Of them, 50,631 are men and 3,587 are women (Swedish Armed Forces, 2022a). This means that Swedish military foreign operations have been clearly dominated by men, although they have clearly not been single-sex operational contexts. Although to some degree, one can say that the social interaction has been built and still builds on the interplay between men and therefore represents a high degree of homosociality. Regarding the distribution between men and women, there is also a Swedish historical context to consider. The Armed Forces have not always been open to women, as it was not until 1989 that women were allowed to have salaried jobs in the Armed Forces on the same terms as men. Gender researchers say that the Armed Forces are still one of the most gender-segregated workplaces in Swedish society (Sundevall, 2011).
After the end of the Cold War, Sweden began cautiously dismantling its Armed Forces, a process that accelerated in the early 21st century. This led to an extensive transformation of the Swedish military, in which the nationwide, conscription-based, anti-invasion defences, including the standing military units (regiments, flotillas, bases), were dismantled and replaced with a small, professionalised expeditionary Armed Forces whose primary focus was to participate on the international scene. After extensive downsizing the few remaining units became a part of the new expeditionary professional defences that evolved with primarily active-duty soldiers/sailors, section commanders, and officers whose primary tasks took place outside Swedish territorial borders. Considering this redirection of the Swedish Armed Forces, significant numbers of career military personnel came to take part in international missions. In particular, the interventions in Afghanistan and Mali turned out to be offensive and dangerous missions that often included planned and unplanned combat and killing. Swedish military personnel were injured and killed; one can say that the military culture in the intervention paradigm in Afghanistan was radicalised to a kind of warrior culture (Abrahamsson, 2010; Grimell, 2021a, 2022a). According to the Swedish Armed Forces’ Veterans Center, five military personnel were killed during the operation. Compiled statistics are lacking when it comes to injuries. However, 23 people have received the Swedish Armed Forces’ medal for Wounded in Combat linked to the operation in Afghanistan. Veterans get that medal for both visible and invisible injuries. This group is missing those injured as a result of accidents.
Although international interventions have historically been part of the Swedish Armed Forces’ missions, the support provided to returning veterans of foreign conflicts has not always reflected this. In other words, there has been a significant gap between the international intervention and the transition to a civilian life. Particularly older veterans of foreign conflicts have criticised the lack of this very important aspect of their international service (Grimell, 2022a). It should be mentioned that, from a complete lack of debriefing in the latter half of the 20th century, where the idea seems to have been to get the veterans home as quickly as possible, today there is a systematic and robust homecoming programme for veterans of foreign conflicts that creates a gentler, well considered transition from the intervention environment to the reality of Swedish civilian life. This programme has been built up gradually over several decades and allows for the rapid introduction of several types of psychological, medical, and other support measures, if the need for them is identified.
A Definition of the Term Veteran
According to the Swedish Armed Forces’ (2022b) definition, everyone who has been an employee of the Swedish Armed Forces and has served on international or national missions, armed or unarmed, is a veteran. However, personnel who have participated in international interventions are called veterans of foreign conflicts, and these are the people who are included in the Armed Forces’ veteran concept. This article focuses on veterans of foreign conflicts, although the word veteran is used by itself for variation.
These two distinct terms, veteran and veteran of foreign conflicts, are important from a medical perspective. The relatively recently established veteran clinic at Uppsala University Hospital specially targets veterans of foreign conflicts. It is the only clinic of its kind in Sweden and is intended for people who have served abroad in war zones or disaster areas on the orders of a Swedish authority; its mission is the assessment and treatment of PTSD or other psychiatric illness linked to this service. Veterans of foreign conflicts can seek treatment at this clinic on their own volition or by specialist referral from another caregiver, no matter where they live in Sweden (Veteran Clinic, 2022).
The Mental Health of Swedish Veterans of Foreign Conflicts: Veteran Health Limbo
On the whole, the Swedish veteran population has good mental health, which should be pointed out as a caveat to an article spotlighting mental health problems. There is ongoing database research that has shown that, at the time of this study, Swedish veterans of foreign conflicts had better mental health after returning home than individuals from the general public of the same sex, age, and year of enlistment; and had as good or somewhat better health than individuals from the general population who were matched with a number of other variables linked to mental health (Aux Analysis AB, 2017, 2021, 2022).
However, in the wake of the international interventions carried out since 1953, of course there are Swedish veterans who struggle with mental health issues, or who have struggled with such problems with various results, depending on the support available to them. Mental health problems among veterans of foreign conflicts in the Swedish population can be understood and described in different ways. One common approach is to estimate the incidence of PTSD at group level. This approach could be described as a medical understanding of mental health issues. In a Swedish context, there are still few, if any, broad survey studies that focus on the incidence of PTSD in the Swedish veteran population. The ongoing database study of mental and physical illness and social outcomes among veterans of foreign conflicts, on which the Swedish Armed Forces bases its estimates, indicates an incidence of PTSD in about 1–5% (with an emphasis of approximately 1–2%) of veterans who served from 1990 and later. The Swedish Armed Forces’ Veterans’ Centre is aware of the risk of incorrect diagnoses and underreporting because not all veterans turn to the healthcare system, sometimes choosing to self-medicate with alcohol, cannabis, or other narcotics (Grimell, 2022a). While the database study excludes veterans of foreign conflicts who served prior to 1990, it gives a good indication of mental illness in the younger portion of the veteran population.
The diagnosis of clinical PTSD, however, is a medical lens that gives a relatively narrow picture of the mental health of the veteran population. There are veterans who have mental health issues and suffer, but who do not meet all the criteria for PTSD and thus do not receive the diagnosis and the medical legitimacy that comes with it. There is very little understanding and knowledge of this group in a Swedish context today. An ongoing qualitative interview study by Grimell, funded by the Swedish Armed Forces’ Veterans’ Centre, aimed to fill this knowledge gap to better understand veterans of foreign conflicts who are experiencing suffering that does not lead to a clinical diagnosis (Uppsala University, Welfare Research Group, Project description of the Veteran Health Limbo, 2021). The study describes the situation of being somewhere between good mental health and a clinically diagnosable condition as Veteran Health Limbo. This is a real problem that manifests, among other things, in the patient flow of the veteran clinic, which features a group of veterans of foreign conflicts who have problems, but do not tick all the boxes for a PTSD diagnosis. Of over 300 patients so far, about 50% of them are patients who have mental health problems, are suffering, but do not meet the criteria for a PTSD diagnosis. In collaboration with the veteran clinic, several of these patients have become participants in the current study on Veteran Health Limbo.
Moral Injury
Moral injury is a relatively new concept that has evolved as a comprehensible lens for understanding the mental health problems of veterans of foreign conflicts whose suffering has not resulted in a clinical diagnosis. At the same time, it should perhaps also be said that moral injury is a concept that has also been found to be relevant for veterans with clinical PTSD, according to a fresh qualitative Swedish interview study, which found that it was common among veterans of foreign conflicts with PTSD to also have moral conflicts and injuries that led to greater suffering and pain than clinical PTSD symptoms alone. In light of the previous (Grimell, 2022a) and now ongoing study on Veteran Health Limbo, as well as research from North America (Barr et al., 2022), moral injury can be understood as a standalone concept that can exist in veterans with and without a PTSD diagnosis.
Moral injury does not yet have the status of a clinical diagnosis, although it is the subject of intense research in a North American context. Nor is there a clear consensus on the term; there are many approaches to defining it that can be said to be related in part to specific characteristics of a given intervention paradigm, and in part to the social context and time in which the concept came to be applied or developed. Morals, that is to say, normative perceptions of right and wrong, are of course something that can be highly charged in an individual’s mind, particularly when related to significant personal and collective sacrifices, such as life and death. A brewing moral conflict that is allowed to grow uninhibited can result in permanent inner moral and emotional pain—a moral injury. This can lead to guilt, shame, bitterness, grief, anger, suspicion, dejection, depression, and questioning of identity.
The term moral injury developed in three waves beginning in the 1990s. Initially, psychologists Shay and Munroe (1998) coined the term in their therapy work with veterans who had served in Vietnam and suffered from PTSD. They said that the veterans felt they were betrayed by a legitimate authority in relation to what they felt was morally right, in high-risk situations. The betrayal was often linked to decisions the soldiers felt conflicted with their combat experience and moral logic of right and wrong. This created a moral injury that traditional therapy had difficulty managing. During the war on terrorism, Litz et al. (2009) expanded this concept, putting the emphasis on violations of the individual’s moral compass in connection with military operations. The latest development of the concept of moral injury, represented by both Atuel et al. (2021) and Grimell (2021b), links moral failures to identity, which can tear apart and cause an individual to question who they are. In this way, a moral injury can be understood as a failure to maintain a morally charged identity with strong ideals and perceptions of what is right and wrong.
The latest wave of development of the term gives a broad, application-friendly approach that allows us to better understand the complexity of mental health problems related to morals and identity (Barr et al., 2022). A veteran of a foreign conflict bears many cultural identities, each with its own normative perceptions of what is morally right. These identities may clash based on the international missions and their lives afterwards. A moral injury does not necessarily have to be linked to a failure to maintain a military identity during a mission. It can also be about a moral failure as a parent, or failing to maintain other life-giving and relationship-related identities because of their international deployment, which resulted in failed relationships, grief, disappointment, guilt, shame, and dejection (Grimell, 2021b, 2022a).
It should also be mentioned that military identities are by nature morally charged with a sort of “boots on the ground” culture and logic that embraces traits such as camaraderie, belongingness, loyalty, discipline, task orientation, and self-sacrifice, which means a risk of creating moral conflict in relation to the institution of the Armed Forces. As mentioned above, there was previously a perceived discrepancy between deployments and homecoming, particularly among veterans of foreign conflicts who served in an era when the Swedish Armed Forces did not offer debriefing and the veterans were sent home as soon as they landed and demobilised. This perceived betrayal of what was seen as morally right (i.e., that the Swedish Armed Forces should live up to the soldiers’ loyalty on their arrival back home), may have negatively affected the veterans’ mental health, as they felt they never got the support they needed in the transitional process and the life that followed, and were never themselves again. This discrepancy and lack of robust support processes may have increased the risk that a number of veterans got stuck in a sort of mental and perceptual limbo, in which they never really found their way back to themselves or their lives. A mental health limbo linked in part to identity reconstruction and adaptation in the transition from a military to a civilian life (Grimell, 2022b), and in part, embracing a permanented moral sense of being let down by someone with legitimate authority (the Swedish Armed Forces) in the aftermath of a high-risk situation (Grimell, 2022a). Currently there are no quantitative studies regarding the incidence of moral injury in a Swedish context.
Support Systems for Veterans Health Limbo Emanating from Moral Injury and Identity
Veterans of foreign conflicts whose mental health problems and suffering become too great can currently turn to the veteran clinic in Uppsala: primary care, conversation hotlines, and peer support from various nonprofit veteran groups in Sweden, corporate healthcare, Försvarshälsan (the Swedish Armed Forces’ healthcare provider for service members), the Church of Sweden, and private psychologists and therapists. Nevertheless, it is not an unreasonable assumption that such veterans trapped in Veteran Health Limbo may also suffer in silence under the stoic warrior mask without seeking help. Perhaps their lives as a whole may still function, even if the individual bears a heavy existential burden of thoughts, musings, identity issues, and internal stressors that affect them negatively in various ways.
As moral injury does not qualify as a clinical diagnosis, there are no effective, evidence-based methods tested with controlled, randomised selection, and control groups. At the same time, research shows that the treatment methods used for PTSD do not work well, or can even be harmful, to those with a moral injury (Atuel et al., 2020, 2021). However, there is both international and national experiences and research that indicates that some practices can work better than others. Moral injury is by nature an existential phenomenon that involves issues of moral violations, betrayal of what is morally right, guilt, shame, bitterness, anger, and identity, which in the long run, appeal to the thoughts of various wisdom traditions on acceptance, forgiveness, and reconciliation (Atuel et al., 2020, 2021; Barr et al., 2022; Grimell, 2021a, 2022a; Koenig et al., 2017; Wortmann et al., 2017). Because of this, both secular therapeutic approaches and spiritual care have come to gravitate towards concepts such as acceptance, forgiveness, and reconciliation, which are considered to be navigable paths when dealing with moral conflicts and moral injury.
In a Swedish context, secular approaches to moral injury such as Adaptive Disclosure (Litz et al., 2017) and Acceptance and Commitment Therapy (Meyer et al., 2018) have not yet gained a foothold, but military spiritual care is an established practice both within and outside the Swedish Armed Forces. Outside the Armed Forces, it can be described as spiritual care of veterans, and one important national actor is the Swedish Soldiers’ Homes Association, which has roots in the Swedish ecclesiastical tradition. The association has soldiers’ homes in connection with most units in Sweden, with directors who perform a kind of social work and military chaplains from the units who often have close local collaboration with the soldiers’ homes and ongoing conversations with the soldiers and veterans of foreign conflicts who seek them out.
As in North America, where research and practice is more advanced, for example in Canada (Smith-MacDonald et al., 2018), there is an incentive to develop a stronger interdisciplinary collaboration regarding moral conflicts and moral injury. Interdisciplinary teams are thought to have a better capacity to quickly identify and address the full complexity of mental health problems.
Peer support is also worth mentioning. Qualitative interview studies illustrate that veterans often tend to turn to fellow veterans and/or comrades from international deployments with their concerns (Grimell, 2018, 2022a). In Sweden, peer support is available both in organised form (e.g., through Sveriges Veteranförbund [the Swedish Veterans Federation]) and on the individual level, where veterans themselves turn to their own kind. No matter what kind of peer support they turn to, it is a pressure relief valve for the veteran to talk out their problems. There is no inhibition when talking to someone who shares one’s own experiences from the field. There is a strength in this kind of peer support, but there is also a risk of getting trapped in a sort of mire of old memories.
Peacetime Sweden
The fact that Sweden has not seen war anywhere in its territory in over 200 years puts the country in a uniquely sheltered context in relation to all the countries around it. Veterans of foreign conflicts have described Swedish society as living in some kind of “peace bubble.” Some have described Swedish culture and civilians in somewhat derogatory terms, like “peace-blindered” and “naïve.” There is a tension between veterans of foreign conflicts and Swedish society, which is characterised by traits such as (a) a very long period of peace, (b) a broad disinterest in the international interventions the Swedish Armed Forces has taken part in far beyond Sweden’s borders, (c) a gradual loss of public support due to the dismantling and professionalisation of the Armed Forces, and (d) an unwillingness on the part of the Armed Forces to spread information and knowledge in society about what types of tasks military personnel have carried out in places like Afghanistan and Mali (Agrell, 2013: Grimell, 2021a, 2022a).
To various degrees, the peacetime society has come to colour the healthcare system in Sweden, both at the primary-care level (the first level that veterans encounter when seeking help for their problems) and the specialist-care level. A recent interview study (see Grimell, 2022a) illustrates that veterans of foreign conflicts have felt misunderstood and even been corrected as to what Swedish troops do internationally (e.g., that they have taken part in combat and killed people). These veterans also reported receiving incorrect diagnoses when seeking care and treatment. Some of these veterans encountered a medical and therapeutic “peace lens” in the healthcare system, for instance, the statement that a help-seeking veteran could not have PTSD because only nations that conduct war have veterans with PTSD, Sweden excluded. However, this qualitative study should not be generalised; it speaks only for the participants in the study (Grimell, 2022a). But there is also quantitative research which suggests that male and female veterans experience the approach and care quality within the Swedish healthcare system less favourable than other patient groups in the population. Female veterans experienced it even worse than male veterans which was suggested to the linked to gender stereotypes (Larsson, 2019).
The veteran clinic established a few years ago at Uppsala University Hospital has been very important to veterans of foreign conflicts (not just those from the Swedish Armed Forces) with mental health problems, and has compensated for the ignorance and shortcomings that some veterans have encountered in primary and specialist care in the 21 independent healthcare regions in Sweden. The veteran clinic has specialised skills and knowledge about veterans of foreign conflicts and medical personnel with military and veteran background who establish trust in the patients due to their specific experience of and insight into the context and nature of international deployment. One challenge that still remains, however, is that investigations conducted by the veteran clinic are not final. Given the structure of the Swedish healthcare system, with its independent regions, these investigations can be reopened and redone when the patient is integrated into their own region’s healthcare system.
Discussion
Moral injury is a type of mental health problem in need of more qualitative knowledge in order to develop methods that provide better, more systematic support for veterans of foreign conflicts. This is important in light of the normative medical tradition and practice that may have unconsciously contributed to a blind spot, or a narrow lens, regarding the understanding of these veterans’ mental health. There is an interaction here that may have spilled over into research and the Swedish Armed Forces’ understanding of the mental health of veterans of foreign conflicts, as the estimated incidence of PTSD has become the norm-giving understanding of the mental health of this veteran group. This blind spot can also lead to a lack of practices for dealing with this type of mental health problem, which corresponds to a moral injury and does not quite fall into the framework of medical care (even when a clinical diagnosis exists).
Moral injury should also be viewed as an existential phenomenon that can arise in veterans of foreign conflicts both during deployment and later in life. Consequently, screening for potential moral injury brings to light a number of questions (Litz et al., 2022). If we screen only for potentially morally damaging experiences and events that occurred during deployment abroad, we can miss an entire lifeworld. Because a moral injury may have arisen due to the international deployment, but the scene of the conflict may be the home or the social context in relationships outside the military environment (Grimell, 2022a). In addition, not everyone who has experienced a potentially morally harmful event develops a moral injury. A moral injury is also a processual and subjective problem that can arise due to new occurrences later in life, which means that it is worthwhile to screen at different points in time. A typical example of this was the fall of Afghanistan and Kabul in 2021, when many Swedish veterans experienced moral conflicts and an acute need to create meaning regarding everything that was happening in relation to all the sacrifices that were made.
Finally, it is important to expand the knowledge and understanding of morally charged identities, moral conflicts, and moral injury among veterans of foreign conflicts. Currently, there is probably very little knowledge about this in the veteran population, as this is a relatively new and unestablished concept. However, PTSD is not a new concept, and in contrast to moral injury, PTSD is a very well-established diagnosis in and outside of the healthcare system in Sweden. It is also a well-established by-product of war, which is portrayed in films and has had some media attention in terms of mental health problems among veterans of foreign conflicts. A combined consequence of this is that there are hardly any complementary interpretative lenses for mental health problems, while at the same time, a complex problem such as moral injury with identity conflicts is difficult to understand from the lens of PTSD. With a better personal understanding of morals and identity, veterans of foreign conflicts can themselves contact a suitable discussion partner to break a moral conflict before it goes too far. Thus, a moral injury can be understood as a process that builds up over a certain time period. Gaining an insight into what is happening in oneself at an early stage can, at least in theory and depending on what the conflict is about, mean the difference between a disarmed conflict and a moral injury that creates significant, perhaps lifelong suffering (Grimell & Nilsson, 2020).
Future Challenges
An important research phase that we are in right now is to carefully develop a deeper empiric picture of how moral injuries might look in veterans of foreign conflicts given the conditions of the Swedish context. In interaction with such qualitative information, we must then expand the picture through quantitative studies to create an idea of the incidence and extent of moral injuries in the veteran population.
The next research phase is a few years in the making and focuses on how to treat veterans of foreign conflicts with moral injuries. This challenge is not unique to Sweden. Essentially all countries that have approached this concept have now put an ever greater focus on treatments and methods, as the concept of moral injury has become more established. One motive is an attempt to find the “gold standard,” a general treatment method for everyone (Litz et al., 2022). However, a gold standard may be difficult to achieve, because a moral injury is dimensional and subjective, as well as the fact that cultures, subcultures, morals, and identities are very different even within a country, even more so between countries.
Given the low level of understanding of international deployment in the Swedish healthcare system, it may be useful to disseminate information in primary care, or during medical training, about the moral problems that Swedish veterans of foreign conflicts may have.
Conclusion
Thus far, moral injury appears to be a fruitful qualitative and complementary lens that focuses on mental health problems in veterans that can co-vary with clinical PTSD and exist independently of a PTSD diagnosis. It is important to gain more knowledge of how this concept can be understood specifically and contextually among Swedish veterans, as well as the incidence of moral injury within the population.
There is a proactive perspective to consider because moral injury is a processual phenomenon. For this reason, the Swedish Armed Forces should, during training, ongoing interventions, and homecoming programmes, develop robust methods for identifying and resolving moral conflicts before they develop into moral injuries.
A stronger interdisciplinary collaboration, possibly an interdisciplinary healthcare team at the veteran clinic, could be a step in the right direction to meet and support veterans with moral conflicts and injuries. Dialogue and interplay within an interdisciplinary healthcare team could also enhance our understanding of effective practice for treating mental health problems and suffering in veterans of foreign conflicts due to moral injury and morally charged identities.
Competing Interests
The author has no competing interests to declare.