Staff Perspective: Moral Injury Related to the US Withdrawal from Afghanistan and a Large-Scale VA Study
A few years ago, I had the privilege of treating an Afghan interpreter who had served alongside U.S. soldiers for several years during Operation Enduring Freedom (OEF); he had witnessed and directly experienced a multitude of traumas. When the U.S. decided to fully withdraw from Afghanistan in August 2021, my patient became incredibly anxious about the safety of interpreters and their families still in that country, as well as his own safety in the U.S. He feared the Taliban would retaliate and come seek revenge on him and his family. His level of hypervigilance almost reached a level of paranoia, but was understandable.
At the same time, he felt guilty that he had been able to leave Afghanistan a few years earlier and was living safely in the U.S., while Afghan colleagues in similar roles whom he had befriended and cared deeply for did not. Frightened they would be hunted down by the Taliban, he anguished over their plight. Needless to say, my patient’s PTSD symptoms and overall distress increased significantly when the U.S. was withdrawing from Afghanistan that August and for weeks afterward as the Taliban took over. At the time, I did not put two and two together and think about how this may have been related to moral injury.
As a refresher, “Moral Injury refers to enduring psychosocial and spiritual harms following exposures to high-stakes events that involve transgressions of one’s deeply held moral convictions or beliefs of right and wrong through one’s own or others’ action or inaction, or perceived betrayal by those in positions of authority or trust.” (Phelps et al., 2022). This type of injury, sometimes called a soul wound, can lead to enduring behavioral health problems that impair relationships and the ability to find meaning in one’s community, including shame, guilt, loss of trust, remorse, hopelessness, self-loathing or even self-condemnation, social isolation, self-harming or reckless behavior, loss of faith, anger, contempt, disillusionment, and feelings of having done something unforgivable. With moral injury, a person perceives that his or her moral or ethical code has been profoundly transgressed—even shattered. This moral violation produces intense internal dissonance because it is irreconcilable with the individual’s expectations about humanity, justice, benevolence, trust, or other core beliefs about themselves, others, and the world. For example, “I’m a good person but I’ve done bad things.” (Wood, 2014).
At the time of the U.S. withdrawal from Afghanistan in August 2021, I knew we were seeing an escalation in PTSD symptoms among some military members who had served in OEF, like my patient. However, the broader implications on how this seminal event might contribute to manifestations of moral injury eluded me.
According to a 17 July article in Military Times (https://www.militarytimes.com/veterans/2023/07/17/va-lays-groundwork-for-first-major-survey-of-moral-injury-in-veterans/): “The military withdrawal from Afghanistan spurred a new rash of moral injury diagnoses, as troops and veterans questioned the meaning of what they’d fought for and grappled with the reality of Afghan allies left behind and in danger.” The article differentiates moral injury from PTSD, noting that moral injury entails a sense of ethical failure and self-betrayal, while PTSD involves re-experiencing past traumatic events. I agree with subject matter experts who have suggested that some service members and veterans may have developed moral injury in part because they felt tremendously betrayed when the U.S. withdrew from Afghanistan and the Taliban took over.
The Military Times article highlights the specific case of Marine veteran Peter Lucier. He experienced morally challenging circumstances during his combat service from 2008 to 2013, but faced a new and unexpected type of moral struggle when he was working as a civilian for Team American Relief, an organization helping evacuate former interpreters and their families from Afghanistan. According to the article, he and some other veterans working for the organization were tasked with filling the seats on an evacuee bus and deciding which women and children most needed to be evacuated and thus had to make heart-wrenching decisions about whom to save. The article describes how it was anguishing emotional work to select for evacuation those they believed were more at risk as opposed to others they also cared about, but were less in need and would remain behind.
This type of morally conflicting situation reminds me of what frontline health care providers confronted during the COVID-19 health emergency. They were put in the precariously difficult position of having to make life-and-death decisions about patients with COVID such as rationing care or following orders they did not believe in. For example, triaging who would receive a ventilator and who wouldn’t, recognizing the person who didn’t get the ventilator likely would die. During the pandemic, we began to hear about the emotional toll such moral and ethical quandaries were taking on health care providers’ well-being. You can read more examples of potentially morally injurious events that health care professionals and military members might experience and how they parallel one another here.
The good news is that the Department of Veterans Affairs will be conducting the first large-scale population study with post-9/11 war veterans to determine the prevalence of moral injury. The main part of the study will include a 30-45 minute online survey that is expected to include 3,000 respondents from across the country. A secondary comparison study will involve interviews with 20 veterans who identify as having moral injury and 20 who do not.
This will be an important study because, to date, no research has measured moral injury as an actual outcome. Rather, studies have used PTSD or depression or guilt, for example, as outcomes when examining the impact of morally injurious events. Thanks to a new and promising measure developed by Litz et al. (2021), the Moral Injury Outcome Scale, this three-year study will be the first of its kind. Hopefully, the results will help us better understand moral injury in post-9/11 war veterans as well as advance our knowledge about this condition in civilians, including what types of morally conflicting events may lead to soul wounds in some individuals.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Paula Domenici, Ph.D., is a Director of Training and Education for the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. She oversees the development of courses and training programs for providers on evidence-based treatments for service members and veterans.
References
Litz, B. T., Plouffe, R. A., Nazarov, A., Murphy, D., Phelps, A., Coady, A., Houle, S. A., Dell, L.,
Frankfurt, S., Zerach, G., & Levi-Bels, Y., and the Moral Injury Outcome Scale Consortium.
(2022). Defining and assessing the syndrome of moral injury. Frontiers in Psychiatry, 13,
923928. https://doi.org/10.3389/fpsyt.2022.923928
Phelps, A., Adler, A. B., Belanger, S. A., Bennet, C., Cramm, H., Dell, L., Fikretoglu, D.,
Forbes, D., Heber, A., Hosseiny, F., Morganstein, J. C., Murphy, D., Nazarov, A., Pedlar, D.,
Richardson, J. D., Sadler, N., Williamson, V., Greenberg, N., & Jetly, R. (2022, June 15).
Addressing moral injury in the military. BMJ Military Health, Advance online publication.
http://dx.doi.org/10.1136/bmjmilitary-2022-002128
Wood, D. (2014. March 18). The grunts: Damned if they kill, damned if they don’t. Huffington
Post. http://projects.huffingtonpost.com/moral-injury/the-grunts
A few years ago, I had the privilege of treating an Afghan interpreter who had served alongside U.S. soldiers for several years during Operation Enduring Freedom (OEF); he had witnessed and directly experienced a multitude of traumas. When the U.S. decided to fully withdraw from Afghanistan in August 2021, my patient became incredibly anxious about the safety of interpreters and their families still in that country, as well as his own safety in the U.S. He feared the Taliban would retaliate and come seek revenge on him and his family. His level of hypervigilance almost reached a level of paranoia, but was understandable.
At the same time, he felt guilty that he had been able to leave Afghanistan a few years earlier and was living safely in the U.S., while Afghan colleagues in similar roles whom he had befriended and cared deeply for did not. Frightened they would be hunted down by the Taliban, he anguished over their plight. Needless to say, my patient’s PTSD symptoms and overall distress increased significantly when the U.S. was withdrawing from Afghanistan that August and for weeks afterward as the Taliban took over. At the time, I did not put two and two together and think about how this may have been related to moral injury.
As a refresher, “Moral Injury refers to enduring psychosocial and spiritual harms following exposures to high-stakes events that involve transgressions of one’s deeply held moral convictions or beliefs of right and wrong through one’s own or others’ action or inaction, or perceived betrayal by those in positions of authority or trust.” (Phelps et al., 2022). This type of injury, sometimes called a soul wound, can lead to enduring behavioral health problems that impair relationships and the ability to find meaning in one’s community, including shame, guilt, loss of trust, remorse, hopelessness, self-loathing or even self-condemnation, social isolation, self-harming or reckless behavior, loss of faith, anger, contempt, disillusionment, and feelings of having done something unforgivable. With moral injury, a person perceives that his or her moral or ethical code has been profoundly transgressed—even shattered. This moral violation produces intense internal dissonance because it is irreconcilable with the individual’s expectations about humanity, justice, benevolence, trust, or other core beliefs about themselves, others, and the world. For example, “I’m a good person but I’ve done bad things.” (Wood, 2014).
At the time of the U.S. withdrawal from Afghanistan in August 2021, I knew we were seeing an escalation in PTSD symptoms among some military members who had served in OEF, like my patient. However, the broader implications on how this seminal event might contribute to manifestations of moral injury eluded me.
According to a 17 July article in Military Times (https://www.militarytimes.com/veterans/2023/07/17/va-lays-groundwork-for-first-major-survey-of-moral-injury-in-veterans/): “The military withdrawal from Afghanistan spurred a new rash of moral injury diagnoses, as troops and veterans questioned the meaning of what they’d fought for and grappled with the reality of Afghan allies left behind and in danger.” The article differentiates moral injury from PTSD, noting that moral injury entails a sense of ethical failure and self-betrayal, while PTSD involves re-experiencing past traumatic events. I agree with subject matter experts who have suggested that some service members and veterans may have developed moral injury in part because they felt tremendously betrayed when the U.S. withdrew from Afghanistan and the Taliban took over.
The Military Times article highlights the specific case of Marine veteran Peter Lucier. He experienced morally challenging circumstances during his combat service from 2008 to 2013, but faced a new and unexpected type of moral struggle when he was working as a civilian for Team American Relief, an organization helping evacuate former interpreters and their families from Afghanistan. According to the article, he and some other veterans working for the organization were tasked with filling the seats on an evacuee bus and deciding which women and children most needed to be evacuated and thus had to make heart-wrenching decisions about whom to save. The article describes how it was anguishing emotional work to select for evacuation those they believed were more at risk as opposed to others they also cared about, but were less in need and would remain behind.
This type of morally conflicting situation reminds me of what frontline health care providers confronted during the COVID-19 health emergency. They were put in the precariously difficult position of having to make life-and-death decisions about patients with COVID such as rationing care or following orders they did not believe in. For example, triaging who would receive a ventilator and who wouldn’t, recognizing the person who didn’t get the ventilator likely would die. During the pandemic, we began to hear about the emotional toll such moral and ethical quandaries were taking on health care providers’ well-being. You can read more examples of potentially morally injurious events that health care professionals and military members might experience and how they parallel one another here.
The good news is that the Department of Veterans Affairs will be conducting the first large-scale population study with post-9/11 war veterans to determine the prevalence of moral injury. The main part of the study will include a 30-45 minute online survey that is expected to include 3,000 respondents from across the country. A secondary comparison study will involve interviews with 20 veterans who identify as having moral injury and 20 who do not.
This will be an important study because, to date, no research has measured moral injury as an actual outcome. Rather, studies have used PTSD or depression or guilt, for example, as outcomes when examining the impact of morally injurious events. Thanks to a new and promising measure developed by Litz et al. (2021), the Moral Injury Outcome Scale, this three-year study will be the first of its kind. Hopefully, the results will help us better understand moral injury in post-9/11 war veterans as well as advance our knowledge about this condition in civilians, including what types of morally conflicting events may lead to soul wounds in some individuals.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Paula Domenici, Ph.D., is a Director of Training and Education for the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. She oversees the development of courses and training programs for providers on evidence-based treatments for service members and veterans.
References
Litz, B. T., Plouffe, R. A., Nazarov, A., Murphy, D., Phelps, A., Coady, A., Houle, S. A., Dell, L.,
Frankfurt, S., Zerach, G., & Levi-Bels, Y., and the Moral Injury Outcome Scale Consortium.
(2022). Defining and assessing the syndrome of moral injury. Frontiers in Psychiatry, 13,
923928. https://doi.org/10.3389/fpsyt.2022.923928
Phelps, A., Adler, A. B., Belanger, S. A., Bennet, C., Cramm, H., Dell, L., Fikretoglu, D.,
Forbes, D., Heber, A., Hosseiny, F., Morganstein, J. C., Murphy, D., Nazarov, A., Pedlar, D.,
Richardson, J. D., Sadler, N., Williamson, V., Greenberg, N., & Jetly, R. (2022, June 15).
Addressing moral injury in the military. BMJ Military Health, Advance online publication.
http://dx.doi.org/10.1136/bmjmilitary-2022-002128
Wood, D. (2014. March 18). The grunts: Damned if they kill, damned if they don’t. Huffington
Post. http://projects.huffingtonpost.com/moral-injury/the-grunts