The military is beginning to recognize a new category of emotional and spiritual injury in war–moral injury, a result of committing or witnessing an event such as an atrocity that violate deeply held ethical beliefs. Experts discuss evolution of the concept, how moral injury occurs, and what psychologists are doing to prevent and treat it when it occurs.
- Dr. Brett Litz, clinical psychologist, VA Boston Healthcare System and Director, Mental Health Core, Massachusetts Veterans Epidemiological Research & Information Center
- Dr. William Nash, co-editor, Combat Stress Injury: Theory, Research & Management and independent consultant, Boston VA Research Institute
15-03 Moral Injury
Reed Pence: When we think of soldiers returning from active duty in a combat zone, one of our biggest concerns is about PTSD, or post-traumatic stress disorder. It’s a familiar term today. Back in World War I, people used to call it shell shock. In World War II it was battle fatigue. PTSD was first used to describe trauma suffered in Vietnam. And now there’s yet another term, something new, something called moral injury, which for the first time takes into consideration the emotional and spiritual injuries of war.
Brett Litz: Moral injury is defined as an experience that reflects a transgression of deeply held beliefs. PTSD as a mental disorder is most often however seen as a mental illness that derives from serious life threat experiences — danger-based experiences. And moral injury is more than that.
Reed Pence: If a soldier commits an atrocity or witnesses a leader commit one, for example, that may trigger moral injury, according to Dr. Brett Litz, a clinical psychologist at the VA Boston Healthcare System and Director of the Mental Health Core of the Massachusetts Veterans Epidemiological Research and Information Center.
Brett Litz: What we believe is that moral injury as an outcome has some PTSD-like manifestations in this form of re-experiencing or being haunted, and then being avoidant because it’s painful to think about. And also shutdown interpersonally because of shame about what took place, but also there are other sequelae that aren’t captured well by the PTSD syndrome. These are self-handicappings, especially if your moral injury reflects a perpetration of some sort. Then individuals may not feel deserving of happiness and deserving of a good life.
Reed Pence: Litz says vets suffering from moral injury might ignore their health, drive recklessly, drink too much, or become suicidal.
Brett Litz: But also moral injury affects people at a spiritual level, and it may not be faith-based but it could be that they’re sort of lost and their moral compass is broken, if you will. And they’re demoralized.
Reed Pence: Many service members block both the memories and emotions associated with moral transgressions.
William Nash: There’s an awful lot of veterans of World War II, Korea, and every other conflict who compartmentalized successfully. You know, they keep all that nastiness in one closed-up box for a good part of their life, and maybe it leaks out in alcohol abuse or a little bit of temper outbursts or maybe not at all.
Reed Pence: That’s Dr. William Nash, former Navy psychiatrist, co-editor of the book Combat Stress Injury: Theory, Research, and Management, and an independent consultant with the Boston VA Research Institute.
William Nash: But then maybe somewhere later on in their life when their coping skills expire, run out, as coping skills all do, they’re all perishable. So sooner or later their ability to keep those wartime experiences compartmentalized to the extent they haven’t really worked through them, and made sense out of them, and made peace with them. Sooner or later there is a good chance they’ll become problematic.
Reed Pence: Nash tells the story of a Marine Gunnery Sergeant he treated after the Vietnam War. The sergeant seemed fine when he returned home and showed no signs of PTSD: no depression, no anxiety, nothing.
William Nash: Until one night he was watching TV at home, and his two daughters who were like eight and ten, were lying on the floor together on the carpet. They fall asleep while watching TV, and they’re just lying there side-by-side. It’s a very nice domestic scene, and he looks down at them and he freaks out, and he snaps and he is never the same again. And he ended up being admitted to the inpatient unit, because he was going out at night with camouflage paint on his face, and he was going out at night crawling through the bushes with a loaded weapon.
Reed Pence: Nash eventually found the root cause of the Sergeant’s change.
William Nash: He recalled an event in Vietnam in which he and some other Marines leveled a Vietnamese village supposedly inhabited by Viet Cong. And he remembers shooting an anti-tank rocket into this straw hooch and blowing it up and it burns. And then after the fire goes out he goes to examine what was in the hooch and he sees two girls lying side-by-side, about ages eight and ten, burnt to a crisp in this hooch. But he totally forgets this memory until that night when he’s watching TV with his two daughters, and from then on he just could not live with himself.
Reed Pence: Not everyone in the military believes moral injury is real. But the same was said about PTSD when it first appeared as a mental health term in the 1980s.
William Nash: Without research to really help us learn more about what were the specific symptoms to look for, and more importantly what was the underlying mechanism of injury, or if it even was an injury. It was just a lot of opportunity for misconceptions. And I remember vividly in the 1980s when I did my psychiatry training and first started treating Vietnam veterans with PTSD, we believed that they had these problems years after the war because they had problems before the war. We believed that a lot of them had pre-existing personality disorders or other life problems or predispositions or something that made them somehow not adapt as well as the other people.
Reed Pence: Research eventually changed that perception of PTSD. Today, moral injury faces the same kind of challenge.
William Nash: And it’s only now, in this war, that we’re beginning to get evidence and see that definitely it isn’t just the weak ones that crumble under stress that end up with a long-term disability. It can and does happen to anyone, and it really is a confirmation of this idea that these are truly injuries.
Reed Pence: One way military leaders hope to prevent moral injury is to prepare soldiers for the horrific situations they may encounter in battling counter-insurgency.
William Nash: Obviously, you can’t prepare someone for the unthinkable, but at least if they are given a chance to experience it through very realistic combat scenarios and training in which children, pregnant women, or old ladies are collaterally killed, unintentionally killed, or intentionally killed, because they are perhaps themselves suicide bombers or some of the other many horrible things that could happen. If, at least, they’re given a chance to role-play these experiences beforehand they might, and then, with good leadership debriefing each training exercise to say okay now if this happens to us for real how are we going to deal with this? So there are people working on that, it’s just very early in the game.
Reed Pence: Prevention of moral injury is obviously the best-case scenario. But how do you treat moral injury once it has taken hold?
Brett Litz: We’ve developed a therapy to target moral injury that we’re testing with Marines, and we did an initial pilot study with Marines and now we’re doing a clinical trial comparing this therapy called adaptive disclosure with an evidence-based therapy that’s used in the VA and the DoD called cognitive processing therapy. There are numerous potentially traumatic experiences and losses and potentially morally injurious experiences that may haunt the person, or they may be having a hard time adapting to. What we seek in this therapy is to get at what is principally harming, what is most haunting, most distressing currently.
Reed Pence: Litz says the technique is akin to a confession. The patient tells the narrative of what they did or saw that was a transgression of deeply held moral values.
Brett Litz: The idea is to get at the raw details and unearth the painful aspects of the experience, and to lay out its meaning and implication in terms of this person, and how they feel about themselves and the world, and their role in the military.
Reed Pence: Then the patient imagines sharing these transgressions with a mentor, such as his father, a chaplain, or a revered coach, someone who the patient has regarded as a compassionate moral authority.
Brett Litz: Share this experience with that person, and hear and voice what this compassionate moral authority would say about that event. And what we’re trying to promote is this idea that moral repair is possible. So if you have someone in your life that loves you and is compassionate about you, but yet is a moral authority, and hears about a transgression — they’ll be upset about that, and they’ll want you to make it right, and they’ll encourage you to make it right because they know you can and that you have goodness in you. So rather than this coming from the therapist, who will have no credibility about that kind of matter, we have the service member in imagination have this dialogue with this compassionate moral authority in their lives, and for them to share what this person is saying about this event and this transgression.
Reed Pence: Nash suggests another approach to healing moral injury as well.
William Nash: The knee-jerk reaction is to say, “oh my gosh it’s all my fault, I’m terrible.” But it’s only when you can really tolerate all that shame and guilt that you can say, “wait a minute now, this is my responsibility, this part is my culpability but this part isn’t.” But it begins with being able to tolerate the horrible emotions, and that’s one of the reasons mindfulness meditation is becoming more and more popular among warfighters. Marines are using it for a number of things, just because it’s a type of meditation where one just tolerates. You sit with yourself, allow the emotions to break on the beach like waves, and just let it be, and then as you develop a tolerance for the emotions then you can start to make sense out of them.
Reed Pence: The concept of moral injury isn’t new. Philosophers and theologians have discussed moral repair and the violations of a shared moral covenant since the antiquity. It’s just that the concept is new to the military.
William Nash: There’s, fortunately, a good number of leaders in the military, at DoD, in the service branches, who understand this and realize that one of the best things they can do for their service members and their families who have felt betrayed by their experiences in wartime is for the services, service branches, and DoD to try to restore their faith in the military as an essentially good institution.
Reed Pence: What is it that makes an experience impossible to incorporate into one’s identity? Researchers believe moral emotions such as shame, guilt, and rage are at the heart of the matter, but they have a long way to go to understand moral injury, as well as diagnose and treat it. In the meantime, families and friends of servicemembers can only do their best to offer support and understanding. If you are a present or former service member and think you might be suffering from moral injury, or if you think you know someone who is, you can call the veterans crisis line at 1-800-273-T-A-L-K or find a link on our website radiohealthjournal.net.
Our writer/producer this week is Polly Hansen. I’m Reed Pence.
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