In a 2011 research article by Kent Drescher, et al titled “An Exploration of the Viability and Usefulness of the Construct of Moral Injury in War Veterans,” there was universal agreement among the subject matter experts interviewed that the concept of “moral injury” is needed to describe and discuss the complex range of consequences of combat. Moral injury arises when a Service member cannot reconcile what he or she has done or experienced in war with his worldview of him or herself prior to war. Commonly this involves killing, especially of non-combatants, often women or children. Especially troubling to the psyche is when the Service member realizes he or she enjoyed the act of killing. Often secrecy, guilt, and shame are at the center of the ensuing internal conflict. And, as Dr. Jonathan Shay describes it, so is a shrinking of what he calls “the moral and social horizon.” When a person’s moral horizon shrinks, he says, so do a person’s ideals and attachments and ambitions. ”It’s titanic pain that these men [sic] live with. They don’t feel that they can get that across, in part because they feel they deserve it, and in part because they don’t feel people will understand it.”
There is considerable discussion and disagreement about defining moral injury. Some believe the term “moral” should be eliminated, while others want to replace the term “injury.” William Nash, M.D., a leading researcher, educator, and clinical consultant in military and veteran psychological health defines moral injury as “stress resulting from perpetrating, or merely witnessing, acts — or failures to act — that transgress deeply held, communally shared moral beliefs and expectations.”
Near the end of 2009, US Department of Veterans Affairs clinicians offered this definition of moral injury: Moral injury is perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations. This may entail participating in or witnessing inhumane or cruel actions, failing to prevent the immoral acts of others, as well as engaging in subtle acts or experiencing reactions that, upon reflection, transgress a moral code.
While moral injury is related to Post-Traumatic Stress Disorder, it is not a defined medical condition and most PTSD experts agree that the construct of moral injury is not adequately covered by the PTSD diagnostic criteria. Unanimously, a group of panel members interviewed in the research conducted by Drescher, et al agreed that PTSD and moral injury are separate but frequently co-occurring problems.
Treating moral injury in combat veterans, Dr. Shay said in a PBS interview, happens not in the clinic, but in the community. Rita Nakashima Brock, Ph.D., author of “Soul Repair” puts it this way, “Moral injury has a slow burn quality that often takes time to sink in. To be morally injured requires a healthy brain that can experience empathy, create a coherent memory narrative, understand moral reasoning and evaluate behavior. Moral injury is a negative self-judgment based on having transgressed core moral beliefs and values or on feeling betrayed by authorities. It is reflected in the destruction of a moral identity and loss of meaning. Its symptoms include shame, survivor guilt, depression, despair, addiction, distrust, anger, a need to make amends and the loss of a desire to live.”
With shame comes isolation, fear of being judged as harshly as they judge themselves, fear of bringing the “toxicity” they feel to others.
As 12-year veteran of the Marine Corps, Tyler Boudreau, who commanded an infantry company in Iraq stated in a 2012 NPR Talk of the Nation segment: “It's very easy for the public, the American public, to say, hey, yeah, let's take care of those Veterans. Let's get them to doctors. Now, with moral injury, the kind of the distinction that I think is so important is it's not necessarily a medical issue anymore. Now it's a social issue. Now, when a Veteran says, ‘Hey, I have a moral injury or I have something that's challenging my moral code,’ that means its challenging society's moral code.
And that means that it's a discussion for everyone, not just the medical community, and it's not enough to just whisk the soldier or the Veteran off to the doctor. It's, hey, we all need to be in this conversation. And we are all, by the way, responsible for whatever transgression that he or she is involved in. That's our transgression, too.”
Dr. Brock also weighs in on the concept of community and societal responsibility. “Moral injury is not a clinical condition that can be medicated or cured by psychology. It requires the reconstruction of a moral identity and meaning system with the support of a caring, nonjudgmental community that can provide a way for Veterans to learn to forgive themselves. But any community that wants to offer such support must have the moral courage to examine its own responsibility for war.”
Recently, in a discussion centering on how to provide best practice therapy when a Service member has played a role in or intended the harm of others, a participant asked ”What do they want? It doesn’t seem to be enough that legal sanctions may be in place and we tell them that what happens in combat is different than in civilian life.“ With more than 20 years treating Service members, it is my belief that what they want and need is the ability to forgive themselves. Being told that they have “paid for their role and responsibility” in a war crime or other incidents; hearing that they followed protocol and did what they were trained to do and being told that their loved ones forgive them is simply not good enough.
An effective method for working with moral injury, especially guilt cognitions, is what Patricia Resick, Ph.D., calls “right-sizing.” When an individual has taken part in or has observed killing, especially of non-combatants, the ensuing guilt of what they did or did not do may be all the individual can see. The act blocks a more global self-perspective, e.g. looking at themselves as a whole. Asking them to recall times they helped others, remembering moments and examples of their kindness and caring may be highly effective interventions for those dealing with a moral dilemma or “dark night of the soul.”
Additionally, and perhaps most importantly, is the societal support needed to engage in a discussion of all the moral questions and the numerous costs of war and the struggle Service members deal with in their attempts to understand what happened to them. Helping them reconstruct a moral identity that can integrate what happened to them in war, may also allow them to want to live and, hopefully, thrive for the rest of their lives.
Laura Copland, MA, LCMHC, is the Senior PTSD Treatment Training for the CDP and a National Cognitive Processing Therapy Trainer.
Brett Litz, et al. "Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy." Clinical Psychology Review 29, no. 8 (2009): 695�706.)
Kent Drescher, et al “An Exploration of the Viability and usefulness of the Construct of Moral Injury in war Veterans.” Traumatology 2011 17:8. Online version: http://tmt.sagepub.com/content/17/1/8