The Health and Well-being of Swedish Deployed Military Veterans

Trauma Exposure, PTSD, and Moral Distress/Moral Injury

Extensive research shows that, during military international deployment, Swedish officers and soldiers are exposed to a variation of work-related stressors (e.g., Michel, 2014). Regarding international health research in a military context, there has generally been a dominant emphasis on trauma exposure and combat-related events. Accordingly, the predominant health outcome of study has involved various aspects of severe stress reactions, i.e., posttraumatic stress disorder (PTSD). Since 2016, the psychological and physical health of Swedish mission abroad veterans have been the emphasis in successive annual cohort studies (Aux Military, 2021b; 2023a). Overall, results showed that Swedish veterans who have served abroad are in a relatively good psychological and physiological health state (Aux Military, 2021b; 2023a; Petrus et al., 2019). This is often attributed to veterans being highly selected, thus generally being fitter and healthier at enlistment than the general population, a tendency referred to as the healthy soldier effect (McMichael, 1976; Pethrus et al., 2019). Another possible explanation may be so-called self-selection, as those more psychologically strong and resilient are assumed to deploy more often (Jacobson et al., 2012).

Research that more specifically emphasizes trauma exposure and the prevalence of PTSD-related symptoms among Swedish veterans is relatively sparse in relation to international contexts. Assessments of probable PTSD (self-report data) has been a minor focus in a few studies aiming to explore the health situation of different groups of military personnel having served abroad since the 1990s. These results show that Swedish veterans do relatively well at the group level. Approximately 2–3% among veterans in large-scale operations, veterans in single service missions, and individuals travelling on a frequent basis (Larsson, Lundell, Svensén, Berglund, & Nilsson, 2018; Larsson, Lundell, Svensén, & Nilsson, 2021; Nilsson et al., 2022) showed indication of PTSD symptoms¹ (≥50, PCL-4, mil. version). Apart from selection effects, stress dose-response may provide another explanation for the low prevalence of PTSD indication among the specific study groups of Swedish mission abroad veterans, as a majority are likely to have less experience of extreme events in comparison to US veterans. Such a hypothesis is supported by a study on Swedish veterans that deploy abroad on a frequent basis (see Table 1 below; Nilsson et al., 2022).

There are, of course, individual differences, and a minor group of veterans suffer from more severe psychological and physiological problems. A recent cohort study (Aux Military, 2023b) looked into the prevalence of PTSD diagnosis from physicians in specialist care among deployed veterans. The results showed that the risk of receiving a PTSD diagnosis is higher among whom have served abroad between 1990–2018, compared to matched controls who have not served abroad. However, it should be noted that the same study also found that other indications of mental illness were less common (Aux Military, 2023b). Due to the lack of studies on PTSD among the Swedish mission abroad veterans group as a whole, such efforts are currently being made. Amyotrophic lateral sclerosis (ALS) has been the emphasis of another study, and results showed that there is a higher prevalence among Swedish mission abroad veterans (Aux Military, 2020). If there is a causal relationship, these results are in contrast to previous studies, on which have continuously shown that Swedish veterans have had good (or better health) compared to matched controls. Yet, the authors (Aux Military, 2020) claimed that it is unclear whether this is due to deployment or the general military lifestyle.

Lately, there has been a growing scholarly interest in veterans coping with psychological distress from morally challenging situations related to military deployment. The concept of moral distress has it’s root in health care research and refers to an individual “knowing the right thing to do, but not being able to pursue the right course of action” (Jameton, 1984, p. 6) due to institutional demands that do not align with one’s own moral conscience. This contributes to the individual perceiving that they are not being able to act in accordance with one’s own morals and standards (Corley, 2002; Jameton, 1984).

In regards to Swedish veterans research, studies on moral distress have been conducted with an emphasis on types of morally distressing situations, coping with such situations, and short and long-term stress reactions following such events. More specifically, studies showed that Swedish mission abroad veterans experience morally challenging situations in terms of conflicts of loyalties and feeling unable to attend to the needs of everyone (i.e., own family, the military organization expectations, conflicting rules and regulations, etc.). Other aspects that tend to create moral constraints on Swedish military officers and soldiers comprised superior leaders not providing enough resources or mandate to allow them be able to shoulder own leader responsibilities. Subsequently, this may instead put subordinates at, what they perceive to be, unnecessary risk. Also, having to relate to mandate (Rules of Engagement, RoE) as well as laws and regulations that are perceived to be contra productive to help the needs in the intervention area. Other aspects contributing to moral stress in the mission area include witnessing the poverty and misery experienced by the locals in the mission area and cultural differences in value systems (e.g., excessive alcohol consumption, prostitution, negative attitudes towards women, corruption, trafficking, abuse, torture, and perceiving oneself unable to act). Additional aspects concern putting locals at risk while performing mission-related tasks, having to prioritize between who to send on risky assignments, or having to kill another human being while on duty, etc. (Kallenberg et al., 2016; Nilsson et al., 2010; Waaler et al., 2019).

In morally challenging situations, Swedish veterans account for acute and cumulative physiological, emotional, and cognitive stress reactions, but also for so-called moral stress reactions. These often include feelings of frustration, powerlessness, meaninglessness, and insufficiency (Larsson, Nilsson, & Waaler, 2018). The moral stress reactions identified differ from those in classical stress literature. Lazarus (1991) regarded meaninglessness and frustration (and helplessness) as so-called ambiguous negative states. These are not emotions in themselves, but rather part of emotions as they constitute part of the antecedent interpretation processes. For that reason, Larsson, Nilsson & Waaler (2018) suggested moral stress reactions constitute a special case of acute stress reactions. In the aftermath of morally challenging situations, the individual is often left ruminating, reproaching oneself or having regrets and wondering, “could I have done more?” Individuals may have difficulties letting go of the situation and suffering from guilt and shame (Nilsson et al., 2010, 2011). A relationship has also been identified between morally challenging situations and indication of PTSD (Larsson et al., 2022).

Strategies identified among Swedish veterans to cope with morally challenging situations have shown to be somewhat problematic. To use problem-focused coping in terms of acting according to one’s own morals and standards to avoid moral distress, often includes having to deviate from laws and regulations, mandate (RoE), or superior leaders’ intent. This includes the risk of juridical repercussions, or at worst, being discharged. Emotion-focused strategies tend to involve rationalizing one’s own decisions or objectifying others, to possibly escape negative emotions such as guilt and shame. This may be favorable in the acute situation to avoid being overwhelmed by one’s own emotions, and be able to stay focused on the task at hand. However, the more long-term psychological consequences of such strategies are unclear. Rationalizing requires the individual to, at least temporarily, shut down emotionally. This, in turn, may reduce empathetic ability, thus risking to make the individual’s discipline deteriorate over time. This may contribute to moral distress by the individual blaming themself in the aftermath for having to degrade others (Nilsson et al., 2010, 2011).

From a leadership perspective, research has indicated that it is also difficult to support subordinates, as there are often no clear right or wrong delineations in many situations, per se. Sometimes leaders may need to report subordinates for deviating from clear mandates, for example, RoE to handle a morally challenging situation. This may contribute to leaders struggling with guilt for letting their subordinates down. It may also lead to morally questionable decisions for the leader, whom may ponder over not reporting the behavior of their subordinates, due to fear of what colleagues or superior leaders may think; wondering if them not reporting action may be interpreted as indirectly supporting those that purposely depart from laws and regulations (Nilsson et al., 2010).

The moral distress theory discussed above places an emphasis on the acute distressing situation, however, moral injury is a similar concept that emerged in the military literature emphasizing more long-term negative health outcomes due to experienced moral distress (Shay, 2003/2004). The concept “moral injury” was initially coined as an expression as scholars became increasingly aware that the emotional and psychological implications from combat and war are complex, and that certain psychological changes are not adequately addressed in the well-defined symptom picture of PTSD (Litz et al., 2009; Nash et al., 2013; Nilsson et al., 2015; Shay, 2003/2004). Even though PTSD-related symptoms were reduced, an inner conflict sometimes remained within the individual, who continued to suffer from, for example, thoughts and feelings of guilt and shame. More specifically, moral injury refers to “psychological/behavioral, social, religious/spiritual, and biological consequences” (Griffin et al., 2019, p. 351) of having “perpetrated, failed to prevent, beared withness to, or learnt about acts that transgress deeply held moral beliefs and expectations” (Litz et al., 2009, p. 697).

Even though moral distress and moral injury theory are conceptually different theoretical frameworks, Grimell and Nilsson (2020) have suggested that moral distress constitutes milder immediate reactions that may be a precondition to the more long-term moral injury. In fact, a recent study (Larsson et al., 2022) exemplifies the importance of acute moral distress for the development of negative long-term ill health (PTSD indication) among Swedish and Norwegian military officers and soldiers. By using the moral distress theory in combination with the moral injury theory in Swedish veteran research, it has been possible to broaden the perspective on moral challenges beyond that of moral injury in the aftermath of trauma exposure and the combat field, to include short-term coping with moral challenges in military contexts. This is suggested as necessary to understand the complex relationships between morally challenging situations/potentially morally injurious events and their possible long-term health effects. The authors will conduct a larger survey study in 2023 to empirically explore the prevalence of, and the relationships between, moral distress and moral injury among Swedish veterans’ further.

Grimell (2022) has studied military veterans suffering from complex PTSD through a moral injury lens, from an identity and spiritual care perspective. He concluded that even though Sweden is less active in combat war zones than many other countries, there are veterans with war zone and combat experiences struggling. Grimell (2021) has also looked into military chaplaincy and pastoral care. These research results are further introduced in a separate article in this special edition of the Journal of Veterans Studies.

Milder Stress Reactions/Symptoms, Everyday Hassles, and Uplifts

As noted above, a majority of Swedish military officers and soldiers having served abroad, from 1990 and onwards, report feeling relatively well at group level, both physiologically and psychologically. Research has indicated that fewer suffer from more severe reactions in terms of PTSD and moral injury. However, regarding research examining low-intense accumulated stress exposure prior to, during, and post-deployment, results showed that Swedish veterans who have served abroad tend to suffer more from milder physical symptoms (back pain, pain in the neck and shoulders), emotional symptoms (i.e., restlessness, sleeping problems, difficulties to relax), as well as cognitive reactions (i.e., forgetting things easily and having difficulties to concentrate; see Larsson, Lundell, Svensén, & Nilsson, 2018; Larsson, Nilsson, & Waaler, 2018; Nilsson et al., 2022). Larsson, Lundell, Svensén, and Nilsson (2018) concluded that it is not possible to say whether these milder symptoms are indeed related to military deployment, yet the emotional and cognitive reactions are often interpreted as being stress-related. Thus, these results may point to a general problem of lack of time for recovery. However, it should be noted that in spite of a higher prevalence of milder reactions among Swedish veterans serving abroad, the study groups showed more favorable results in comparison to a norm group consisting of female and male leaders in the Swedish business sector (Larsson, Lundell, Svensén, & Nilsson, 2018; Larsson, Nilsson, & Waaler, 2018; Nilsson et al., 2022).

Larsson et al. (2017) argued that the strong, and relatively one-sided, emphasis on more severe stress reactions often focused upon in US research, means that we know less about milder sub-clinical reactions among veterans in general, in comparison to severe stress reactions. Therefore, the authors suggested an alternative approach to health by looking more into the importance of daily hassles and uplifts among Swedish veterans who have served abroad. This approach was based on the idea that the effects of major life crises on health and well-being may be mediated through the appraisal of daily events (DeLongis, et al., 1982; Gruen, et al., 1988). For example, recent research has repeatedly found that accumulated daily hassles show stronger relationships with physical and psychological symptoms than major stressful episodes (Heron et al., 2013; Larsson, Lundell, Svensén, & Nilsson, 2018; Larsson, Ohlsson, Berglund, & Nilsson, 2017; Stefanek et al., 2012). Two studies—one consisting of 1,859 veterans who served abroad in large scale units between 2011–2015 (Larsson, Lundell, Svensén, & Nilsson, 2018), and 653 individuals in a single service mission between 1990–2015—support a hypothesis of the importance of daily events for understanding long-term health outcomes, i.e., PTSD indications (Larsson, Lundell, Svensén, Berglund & Nilsson, 2018). More specifically, results showed that the stronger the combination of daily uplifts and functional coping strategies is in relation to the combination of daily hassles and dysfunctional coping strategies, the lower the prevalence of enduring illness and PTSD indication (Larsson et al., 2017, 2021). The authors suggested that these findings contribute to the knowledge of how everyday events and coping strategies may contribute to long-term ill health. Thus, the prevalence of milder symptoms among Swedish veterans who have served abroad may be argued to perhaps constitute a vulnerability at group level that needs to be further attended to. The authors additionally pointed to the practical use of a scientific approach that emphasize daily events from an intervention perspective. While it is often very difficult, if not impossible, to affect major life events, it is easier to change more daily lifestyles (Larsson et al., 2017, 2021).

Social Outcomes: Work-Life Balance and Deployment Implications on Romantic Couples

In the successive annual cohort studies mentioned earlier, social outcomes of Swedish mission abroad veterans were also explored (Aux Military, 2021c). Results showed that Swedish veterans indicate a higher divorce rate (almost double) after deployment besides a lessen propensity to marry compared to matched controls (Pethrus et al., 2019). Olsson and Olsson (2019) have also explored Swedish families’ experiences of hardships related to deployment, whereas a recent study showed that concerns about the constant strain and future family building constitute a potential reason for leaving the military among newly employed Swedish officers (Oskarsson et al., 2021). Ohlsson et al. (2021) found that Swedish military officers who stay in the profession over time often find the need to find a partner that will accept the military demands and lifestyle, thus preventing friction regarding work-private life balance. Weibull (2009) has investigated the need for support amongst Swedish families. Taken together, these results point to an area of potential weakness for romantic couples among Swedish mission abroad veterans. Based on these findings, Nilsson et al. (2019) conducted an initial explorative study to explicate potential factors contributing to the identified relationship between deployment and social outcomes in terms of a higher propensity to divorce among couples, which was followed up by a quantitative test of the identified factors or mechanisms (Nilsson et al., 2021). According to the results (see Figure 1 below), a Demand-Resources Balance Model was suggested to be a core variable to understand the impact of international military deployment on couple well-being among Swedish mission abroad veterans. On the one side of the balance act, work and relationship-related demands were explicated. On the other side, individual and shared resources. It was suggested that the more favorable resources, including basic prerequisites and coping strategies of both the veteran and the partner, and the perception that the fewer the demands experienced, constitutes a more favorable starting point for the couple to handle the deployment, and vice versa.

Figure 1

On a more specific level, the results of Nilsson et al. (2019) illustrated how the veteran and spouse respectively, as well as the couple together, were often confronted with a number of continuous work and relationship-related demands that can be both favorable and unfavorable. When incompatible, inter-role conflicts arose, affecting private life, and risking a weakening of the romantic relationship over time. The x and y-axis in the upper box of the figure (see Figure 1 above), illustrate a constant high level of demands for Swedish mission abroad veterans, although their nature tend to differ depending on context (before, during, after deployment). The model contributes to existing knowledge by previous holistic models not being military-context-specific or taking account for the complexities of today. The model addresses continuous turbulences and change from a cyclic time-perspective, which is suggested essential to understand individual appraisal and re-appraisal processes of demands and coping strategies to handle such demands, and in consequence, romantic relationship interactions and fluctuations related to the complexities of deployment. The time perspective is suggested important as, for example, negative experiences resulting in relationship struggles short-term, has proven to sometimes strengthen romantic couples long-term. The figure is also unique in that it includes both private and working-life demands with a couple’s perspective in relation to one’s personal work demands. By doing so, it integrates both spheres into a perspective of demands and resources that does not merely isolate one aspect of an individual’s life, but which raises question related to the role of the military in shaping people’s lives from a life course perspective (see for example, Wilmoth & London, 2013).

Overall, the authors (Nilsson et al., 2019) concluded that the results of the theoretical model are similar to those identified in previous research. Specific demands were shown to concern the profession’s general nature regarding, for example, the need to travel and a high workload, making it difficult for the couple to share a common everyday life. At times, private life was perceived as an obstacle for being efficient at work. The results indicated that, in general, the person traveling is inclined to find themself insufficient as a partner, resulting in a bad conscience for being away a lot; whereas the partner at home tends to feel abandoned and not prioritized as a result.

In Nilsson et al. (2021), deployment was shown to often reinforce the aforementioned, already-existent continuous work and relationship-related issues, by the individuals living somewhat parallel lives, which included having trouble communicating. The study concluded that the cumulative strain of the couple being temporarily apart (repeatedly among those travelling on a frequent basis) may create accumulated stress in the relationship over time, with the risk of the couple sliding apart, and in the end deciding to go separate ways. On the contrary, favorable basic prerequisite and coping strategies, may leave the couple relatively unaffected by the temporary separation, or even strengthen the relationship. In the quantitative follow up study (Nilsson et al., 2021), those couples having separated since their last deployment, consistently scored higher on demands and less on the favorable coping strategies, and vice versa among those couples still living together. This attest to the relevance of the challenges and coping strategies identified in the initial explorative study (see Nilsson et al., 2019).

It should be noted that the study results differ from previous research (see for example Monson et al., 2009) by not accounting mental illness to be the main explanation to separation following expeditionary service. In a Swedish mission abroad veteran context, relationship-related problems seem to primarily involve milder reactions related to work-life conflict, tending to aggravate the temporary separation, as well as reintegration and the couple reconnecting emotionally post-deployment. Yet, it is relevant to point out that there was a higher prevalence of PTSD indication among those veterans having separated, which may point to more severe stress reaction constituting a vulnerability factor that may still be relevant to explore further related to couple satisfaction after military deployment (Nilsson et al., 2019, 2021).

Another line of Swedish veteran research that relates to military families, includes dialogical participation action research, towards the discovery of tools that can serve military individuals’ families (especially the children) by buffering against the challenges they face when a family member participates in international military deployments (Olsson & Olsson, 2019, p. 5).

Veteran Support

Should post-mental health problems arise, Swedish mission abroad veterans are advised to contact their local primary health care provider. Thus, military veterans receive support for physical and psychological stress reactions from the general health care system in Sweden. However, a study showed that veterans having sought help, perceived the quality of care as less than satisfactory, which may be due to a lack of awareness of the special conditions among medical personnel that military veterans are subjected to (Larsson, 2019). Despite this, there is help to be offered in areas that are assessed to be clinically significant, both at the primary care level (addressing physical and psychosocial difficulties) and at specialized level, such as treatment for severe stress reactions including PTSD and burnout. Veteranmottagningen at Uppsala University Hospital constitute an example of this.

There are other types of support for veterans, which are more context-specific but are typically offered by nonprofit organizations rather than the health and welfare system in Sweden. Specifically related to couples, an evidence-based prevention and relationship education program (PREP) for Strong Bonds is used in several countries. PREP for Strong Bonds is an adapted form of the original PREP used by military branches. It has been used in the US Military since 1991, and it is generally provided by military chaplains (Allen et al., 2017). The content was modified for use in the military, including the addition of modules on deployment and family separation (Bakhurst et al., 2017). This intervention is routinely offered for Swedish military personnel and their partners from a nonprofit organization that works cooperatively with the SAF. This supportive intervention is used to developed and teach couples communication skills to prevent problems or improve relationship functioning. There are other types of support available by nonprofits, such as economic support for acute need (VVR Veteranstöd Rapid Reaction) and counselling support for family by others that have been through similar experiences (e.g., peer support).