Skip to Main Content

Psychology and Law
2025. Vol. 15, no. 4, 275–297
doi:10.17759/psylaw.2025150415
ISSN: 2222-5196 (online)

"The Ajax effect": The role of moral injury-related dissociation in the evolution of suicidal behavior during combat stress

 
Audio is AI-generated
1

, ,

PDF (RUS)
Online translation in english
GS
Information
in Google Scholar
Metrics

Abstract

Context and relevance. Combatants and combat veterans, due to the specific nature of their experiences, may face an elevated risk of suicidal ideation and behavior, rendering suicide prevention a critical challenge. Understanding the variables in the dynamics of suicidality genesis and resilience factors is crucial for improving risk prediction and developing effective psychological intervention and prevention strategies. Objective. To present and theoretically substantiate a model of the psychological mechanisms underlying the transition from moral injury to suicidal behavior among combatants and combat veterans, considering the mediating role of dissociation. The practical purpose of the model is the reasonable prevention of behavioral risks. Hypothesis. The model hypothesizes that moral injury, through negative cognitive-affective states (e.g., shame, guilt, entrapment), leads to suicidal ideation, while dissociation, exacerbated by resilience deficits, catalyzes the transition to suicidal action. Methods and materials. A review and analysis of scientific literature on moral injury, combat stress, suicide, and dissociation among military personnel were conducted; theoretical modeling of the mechanisms by which dissociation and moral injury influence suicidal behavior was performed. Results and discussion. A model was developed illustrating the pathway from potentially morally injurious events and moral injury to suicidal behavior, mediated by cognitive-affective variables, dissociation, and resilience deficits (termed the 'Ajax effect'). Types of moral injury and the typology of potentially morally injurious events were analyzed in the context of suicide risk. Conclusions. The proposed model conceptualizes how moral injury and dissociation can contribute to an increased risk of suicide among combatants and combat veterans, which provides a basis for the development of more accurate diagnostic methods and targeted preventive measures. Dissociation, accompanied by reduced pain sensitivity and detachment from experiences, can facilitate the transition from suicidal thoughts to actions, which underscores the importance of addressing this mechanism for the purpose of suicide prevention.

General Information

Keywords: moral injury, potentially morally injurious events, "Ajax effect", combat stress, suicidal thoughts and behavior, dissociation, shame and guilt

Journal rubric: Interdisciplinary Studies

Article type: scientific article

DOI: https://doi.org/10.17759/psylaw.2025150415

Funding. The study was supported by the Russian Science Foundation, project number 24-28-01847, https://rscf.ru/project/24-28-01847/

Received 20.01.2025

Revised 20.03.2025

Accepted

Published

For citation: Sagalakova, O.A., Truevtsev, D.V., Zhirnova, O.V. (2025). "The Ajax effect": The role of moral injury-related dissociation in the evolution of suicidal behavior during combat stress. Psychology and Law, 15(4), 275–297. (In Russ.). https://doi.org/10.17759/psylaw.2025150415

© Sagalakova O.A., Truevtsev D.V., Zhirnova O.V., 2025

License: CC BY-NC 4.0

References

  1. Dnov, K.V., Bart, D.A., Demina, S.D., Kazandzhan, G.P., Tyagnerev, A.T., Yatmanov, A.N. (2024). Suicidal behavior of servicemen: retrospective study. Marine Medicine, 10(4), 111—119. (InRuss.). https://doi.org/10.22328/2413-5747-2024-10-4-111-119
  2. Zelenina, N.V., Chernyavskiy, E.A., Fedotkina, I.V., Starenchenko, Yu.L., Yusupov, V.V. (2024). Diagnostics of the level of mental disorder in combatants with acute stress disorder on the stage of hospital rehabilitation. Clinical Psychology and Special Education, 13(2), 46—60. (In Russ.). https://doi.org/10.17759/cpse.2024130203
  3. Kadyrov, R.V., Dmitrieva, O.B. (2021). Moral Injury: Modern Approaches to the Definition of the Concept, Etiology, Diagnosis, and Psychotherapy. The Bulletin of Kemerovo State University, 23(2), 438—446. (In Russ.). https://doi.org/10.21603/2078-8975-2021-23-2-438-446
  4. Karayani, A.G. (2024). Combat stress: problems of definition and classification. Bulletin of the Moscow University of the Ministry of Internal Affairs of Russia,1, 254—264. (In Russ.). https://doi.org/10.24412/2073-0454-2024-1-254-264
  5. Kitayev-Smyk, L.A. (2001). Stress of the war: frontline observation of a clinical psychologist. Moscow: Ministry of Culture of the Russian Federation; Russian Institute of Cultural Studies.(In Russ.).
  6. Kryukov, E.V., Shamrey, V.K., Marchenko, A.A., Lobachev, A.V., Khabarov, I.Yu., Kolodin, S.N. (2023). Post-Traumatic Stress Disorder: Evolution of Views. Psychiatry (Moscow), 21(4), 57— (In Russ.). https://doi.org/10.30629/2618-6667-2023-21-4-57-71
  7. Sagalakova, O.A., Truevtsev, D.V., Zhirnova, O.V. (2022). Rumination as a psychological mechanism in the suicidal behavior formation and maintenance. Journal of Modern Foreign Psychology, 11(1),124— 136. (In Russ.). https://doi.org/10.17759/jmfp.2022110112
  8. Sagalakova, O.A., Truevtsev, D.V., Zhirnova, O.V. (2025). The Psychological Role of Dissociation and Repetitive Negative Thinking in the Development of Suicidal Behavior in Posttraumatic Stress Disorder. Neurology Bulletin, 57(2), 180—193. (In Russ.). https://doi.org/17816/nb642098
  9. Sagalakova, O.A., Truevtsev, D.V., Sagalakov, A.M. (2016). Impaired cognitive regulation of social anxiety in individual behavior. Tomsk: Tomsk State University Publ. (In Russ.).
  10. Stolyarenko, A.M. (2008). Extreme psychopedagogy A textbook for universities. Moscow:YUNITI-DANA. (In Russ.).
  11. Sukiasyan, S.G., Grigoryan, A.K., Tadevosyan, M.Ya., Babakhanyan, A.A. (2024). The Prognostic Value of Combat Trauma Symptoms for the Early Development of Post-traumatic Stress Disorders. Current Therapy of Mental Disorders, 1, 2—9. (In Russ.). https://doi.org/10.21265/PSYPH.2024.42.71.001
  12. Kholmogorova, A.B. (2016). Suicidal behavior: theoretic model and practical implications in cognitive-behavioral therapy. Counseling Psychology and Psychotherapy, 24(3), 144—163. (In Russ.). https://doi.org/10.17759/cpp.2016240309
  13. Chistopolskaya, K.A., Kolachev, N.I., Enikolopov, S.N. (2023). Questions for Suicide Risk Assessment: There, Then and How to Measure? Counseling Psychology and Psychotherapy, 31(2), 9—32. (In Russ.). https://doi.org/10.17759/cpp.2023310201
  14. Shamrey, V.K., Kurasov, E.S., Kolchev, A.I., Starostina, E.V. (2025). Combat mental pathology: from the evolution of views to modern concepts. Russian Journal of Psychiatry, 1, 5—12. (In Russ.). URL: https://www.elibrary.ru/item.asp?id=80545798 (viewed: 15.01.2025).
  15. Bonson, , Murphy, D., Aldridge, V., Greenberg, N., Williamson, V. (2024). Veterans' experiences of moral injury, treatment and recommendations for future support. BMJ Military Health, 170(e2), e104—e109. https://doi.org/10.1136/military-2022-002332
  16. Bryan, J., Bryan, A.O., Roberge, E, Leifker, F.R., Rozek, D.C. (2018). Moral injury, posttraumatic stress disorder, and suicidal behavior among National Guard personnel. Psychological Trauma: Theory, Research, Practice and Policy, 10(1), 36—45. https://doi.org/10.1037/tra0000290
  17. Campbell, K.A. (2023). Dissociation: An overlooked concern in military training and an important factor in suicide. European Journal of Trauma & Dissociation, 7(4), Article 100351. https://doi.org/10.1016/j.ejtd.2023.100351
  18. Caulfield, N.M., Karnick, A.T., Capron, D.W. (2022). Exploring dissociation as a facilitator of suicide risk: A translational investigation using virtual reality. Journal of Affective Disorders, 297, 517—524. https://doi.org/10.1016/j.jad.2021.10.097
  19. Christoforou, C. (2022). Combat Trauma and Ajax: A Script-Based Approach. In: O. Rees, K. Hurlock, J. Crowley (Eds.), Combat Stress in Pre-modern Europe. Mental Health in Historical Perspective. Palgrave Macmillan, Cham (pp. 63—82). https://doi.org/10.1007/978-3-031-09947-2_4
  20. Currier, J.M., Farnsworth, J.K., Drescher, K.D., McDermott, R.C., Sims, B.M., Albright, D.L. (2018). Development and evaluation of the Expressions of Moral Injury Scale-Military Version. Clinical Psychology & Psychotherapy, 25(3), 474—488. https://doi.org/10.1002/cpp.2170
  21. Houle, S.A., Ein, N., Gervasio, J., Plouffe, R.A., Litz, B.T., Carleton, R.N., Hansen, K.T., Liu, J.J.W., Ashbaugh, A.R., Callaghan, W., Thompson, M.M., Easterbrook, B., Smith-MacDonald, L., Rodrigues, S., Bélanger, S.A.H., Bright, K., Lanius, R.A., Bake, C., Younger, W., Bremault-Phillip, S., Nazarov, A. (2024). Measuring moral distress and moral injury: A systematic review and content analysis of existing scales. Clinical Psychology Review, 108, Article 102377. https://doi.org/10.1016/j.cpr.2023.102377
  22. Johnson, J., Gooding, P.A., Wood, A.M., Tarrier, N. (2010). Resilience as positive coping appraisals: Testing the schematic appraisals model of suicide (SAMS). Behaviour Research and Therapy, 48(3), 179—186. https://doi.org/10.1016/j.brat.2009.10.007
  23. Joiner, T. (2005). Why people die by suicide. Cambridge, MA. Harvard University Press.
  24. Kelley, M.L., Chae, J.W., Bravo, A.J., Milam, A.L., Agha, E., Gaylord, S.A., Vinci, C., Currier, J.M. (2021). Own soul's warning: Moral injury, suicidal ideation, and meaning in life. Psychological Trauma: Theory, Research, Practice and Policy, 13(7), 740—748. https://doi.org/10.1037/tra0001047
  25. Klonsky, E.D., May, A.M. (2015). The Three-Step Theory (3ST): A new theory of suicide rooted in the “ideation-to-action” framework. International Journal of Cognitive Therapy, 8(2), 114—129. https://doi.org/10.1521/ijct.2015.8.2.114
  26. Lamontagne, S.J., Zabala, P.K., Zarate Jr, C.A., Ballard, E.D. (2023). Toward objective characterizations of suicide risk: A narrative review of laboratory-based cognitive and behavioral tasks. Neuroscience & Biobehavioral Reviews, 153, Article 105361. https://doi.org/10.1016/j.neubiorev.2023.105361
  27. Lathan, E.S., Sheikh, I.S., Guelfo, A., Choucair, K.C., Fulton, T., Julian, J., Mekawi, I., Currier, J.M., Powers, A., Fani, N. (2023). Moral injury appraisals and dissociation: Associations in a sample of trauma-exposed community members. Journal of Trauma & Dissociation, 24(5), 692—711. https://doi.org/10.1080/15299732.2023.2231010
  28. Levi-Belz, Y., Zerach, G. (2018). Moral injury, suicide ideation, and behavior among combat veterans: The mediating roles of entrapment and depression. Psychiatry Research, 269, 508—516. https://doi.org/10.1016/j.psychres.2018.08.105
  29. Litz, B.T., Stein, N., Delaney, E. (2009). Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695—706. https://doi.org/10.1016/j.cpr.2009.07.003
  30. Maguen S., Griffin B.J., Vogt D., Hoffmire C.A., Blosnich J.R., Bernhard P.A., Akhtar F.Z., Cypel Y.S., Schneiderman A.I. (2023). Moral injury and peri- and post-military suicide attempts among post-9/11 veterans. Psychological Medicine, 53(7), 3200—3209. https://doi.org/10.1017/S0033291721005274
  31. Murray, H., Ehlers, A. (2021). Cognitive therapy for moral injury in post-traumatic stress disorder. Cognitive Behaviour Therapist, 14, Article 8. https://doi.org/10.1017/S1754470X21000040
  32. Nichter B., Hill M., Norman S., Haller M., Pietrzak R.H. (2020). Impact of specific combat experiences on suicidal ideation and suicide attempt in U.S. military veterans: Results from the National Health and Resilience in Veterans Study. Journal of Psychiatric Research, 130, 231—239. https://doi.org/10.1016/j.jpsychires.2020.07.041
  33. O'Connor, R.C., Kirtley, O.J. (2018). The integrated motivational-volitional model of suicidal behavior. Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences, 373(1754), Article 20170268. https://doi.org/10.1098/rstb.2017.0268
  34. Pachkowski, M.C., Rogers, M.L., Saffer, B.Y., Caulfield N.M., Klonsky E.D. (2021). Clarifying the Relationship of Dissociative Experiences to Suicide Ideation and Attempts: A Multimethod Examination in Two Samples. Behavior Therapy, 52(5), 1067—1079. https://doi.org/10.1016/j.beth.2021.03.006
  35. Park, N., Park, M., Peterson, C. (2010). When is the search for meaning related to life satisfaction? Applied Psychology Health and Well-Being, 2(1), 1—13. https://doi.org/10.1111/j.1758-0854.2009.01024.x
  36. Rabasco, A., Andover, M.S. (2020). The interaction of dissociation, pain tolerance, and suicidal ideation in predicting suicide attempts. Psychiatry Research, 284, Article 112661. https://doi.org/10.1016/j.psychres.2019.112661
  37. Rogers, M.L., Hagan, C.R., Joiner, T.E. (2018). Examination of interoception along the suicidality continuum. Journal of Clinical Psychology, 74(6), 1004—1016. https://doi.org/10.1002/jclp.22564
  38. Rudd, M.D. (2006). Fluid vulnerability theory: A cognitive approach to understanding the process of acute and chronic suicide risk. In: T.E. Ellis (Ed.). Cognition and suicide: Theory, research, and therapy(pp. 355—368). American Psychological Association. https://doi.org/10.1037/11377-016
  39. Steger, M.F., Frazier, P., Oishi, S., Kaler, M. (2006). The meaning in life questionnaire: Assessing the presence of and search for meaning in life. Journal of Counseling Psychology, 53(1), 80—93. https://doi.org/10.1037/0022-0167.53.1.80
  40. Turecki G., Brent D.A., Gunnell D., O'Connor R.C., Oquendo M.A., Pirkis J., Stanley B.H. (2019). Suicide and suicide risk. Nature Reviews Disease Primers, 5, Article 74. https://doi.org/10.1038/s41572-019-0121-0
  41. Williamson, V., Greenberg, N., Murphy, D. (2021). Predictors of moral injury in UK treatment seeking veterans. Child Abuse & Neglect, 112, Article 104889. https://doi.org/10.1016/j.chiabu.2020.104889
  42. Zerach, G., Levinstein, Y., Levi-Belz, Y. (2024). Longitudinal associations between exposure to potentially morally injurious events and suicidal ideation among recently discharged veterans — The mediating roles of depression and loneliness. Journal of Affective Disorders, 350, 689—697. https://doi.org/10.1016/j.jad.2024.01.125

Information About the Authors

Olga A. Sagalakova, Candidate of Science (Psychology), Associate Professor, Senior Researcher, Laboratory of Experimental Pathopsychology, Moscow State University of Psychology and Education, Moscow, Russian Federation, ORCID: https://orcid.org/0000-0001-9975-1952, e-mail: olgasagalakova@mail.ru

Dmitry V. Truevtsev, Candidate of Science (Psychology), Associate Professor, Senior Researcher, Laboratory of Experimental Pathopsychology, Moscow State University of Psychology and Education, Moscow, Russian Federation, ORCID: https://orcid.org/0000-0003-4246-2759, e-mail: truevtsev@gmail.com

Olga V. Zhirnova, Junior Researcher, Laboratory of Experimental Pathopsychology, Moscow State University of Psychology and Education, Medical Psychologist, Altai Regional Clinical Psychiatric Hospital Named J.K. Erdman, Barnaul, Russian Federation, ORCID: https://orcid.org/0000-0002-6680-8286, e-mail: olga.zhirnova.2015@mail.ru

Metrics

 Web Views

Whole time: 4
Previous month: 0
Current month: 4

 PDF Downloads

Whole time: 1
Previous month: 0
Current month: 1

 Total

Whole time: 5
Previous month: 0
Current month: 5