A colleague of mine once asked if I had heard of the term “moral injury” as it relates to post-deployment concerns and PTSD. At the time, I had not seen it used formally, but the term intuitively made sense to me. I thought about my clinical work conducting post-deployment behavioral health screenings; during those screenings, some patients described feeling “different” after deployment experiences, but struggled to put this feeling into words and did not have symptoms typically associated with PTSD. My colleague then mentioned a book on the topic, “Soul Repair,” by Rita Nakashima Brock and Gabriella Lettini, which I dutifully borrowed, but put off reading due to my busy schedule (or so I tell myself). After reading Laura Copland’s earlier Staff Perspective article detailing the varying definitions of moral injury and how this concept relates to Service members and Veterans, I decided to tackle my to-do list more thoroughly and finally read this book. Below, I provide my critique, first by giving an overview of the book and its strengths, followed by highlighting its weaknesses and then finally suggesting future directions on this important topic.
“Soul Repair” interweaves discussion of moral injury with the stories of a number of Service members; four Service members in particular are highlighted. Mac is a Vietnam veteran who felt alienated and judged by society after returning, who lost a marriage and went through a period of substance abuse before finding meaning in helping other veterans and teaching philosophy. Herm is also a Vietnam veteran, a chaplain who suffered several major injuries before returning to his wife and infant son, initially dependent on them for physical care, but staying on active duty for several decades. Pamela is a Veteran, and the mother of an Army Veteran, whose son struggled with anger at authorities for starting war and difficulty getting VA care. Camilo is a Nicaraguan immigrant from Costa Rica who was extended in service via a “stop-loss” and has since become an activist supporting conscientious objection. In addition to the Service members interviewed for the book, both authors are family members of Veterans. They share their personal experience as the daughter of a World War II and Vietnam veteran, and as the cousin of an Italian army veteran, respectively. As a mental health provider, I love hearing others’ stories and perspectives, so I found these sections of the book particularly interesting.
The authors use these stories to transition to suggestions to aid in recovering from moral injury. From an individual perspective, they encourage Veterans to form friendships with both other Veterans as well as civilians, to volunteer and find ways to “make a positive difference in the world”, and in general to pursue activities that will help them redefine a sense of meaning. For our society as a whole, the authors suggest rather than deferring responsibility for war-related mental health outcomes to the country’s leaders or to mental health providers, that people in general should be willing to listen to Veterans without judgment, and express support for both meaning-making and personal forgiveness. I found the emphasis on reintegration back into civilian life as incumbent upon the community and not just the individual particularly important. For example, the authors write about an incongruence between the camaraderie and heavy moral issues in the military with the “consumption and entertainment driven society” in which we live. Service members, especially those serving in the Guard or Reserve, may return from deployment to communities that do not seem to notice, much less appreciate, military service. This can exacerbate any feelings of disconnect that were already present.
However, the authors frequently use either conscientious objector status (e.g. deploying despite disagreeing ethically or morally with a military conflict) or serving in any capacity during wartime in describing moral injury examples. Their conceptualization is in sharp contrast to the one adopted by the National Center for PTSD, which uses Litz and colleagues’ (2009) definition of moral injury: “to transgress deeply held moral beliefs and expectations.” Litz and colleagues’ definition implies to me that the trigger for moral injury could fall within a very broad range, including not just purposeful behaviors but thoughts, feelings, observations, etc. It also implies to me that moral injury is relative, as moral beliefs may vary by individual and the depth of each belief may also vary by individual. Thus, the focus in “Soul Repair” on conscientious objection as a primary trigger for moral injury seems limited and viewing military service in and of itself during wartime as a moral injury seems not to capture the individual nature of this definition.
Perhaps the primary benefit of a book on moral injury in the military population is simply to increase awareness of the potential development of moral injury during military service and spur interest in taking action in some way. For example, as mental health providers we may want to take on military-connected patients or seek out training on treating moral injury, or as family members and friends we may want to avoid asking insensitive questions that could aggravate moral injury. However, I found certain language of the book, such as repeatedly using terms like “unjust war” or “immoral war” to be unnecessarily political and detract from focusing specifically on the impact of moral injury. Moreover, from a personal viewpoint as a former Service member some of the language could be taken offensively, such as stating that serving in a support MOS “was the same as those who did the killing”, that the military “trains ordinary young people to be killers” or that “not walking away” during a deployment reflects a “lack of courage”. While it is possible these thoughts reflect the opinion of the Service members followed in the book or those of the authors, I feel that not making attributions construes the statements as fact.
I thought that the book would be improved by the inclusion of additional experiences that may trigger traumatic injury, such as witnessing children die or be used as shields by insurgents, treating wounded Service members and local patients with horrific injuries (see case study of a young girl assaulted by her family in Blount et al, 2014), and duties in the morgue as well as combat roles. These were the kinds of triggers I heard clinically. I also would like to hear stories from Service members who did not disagree with war, but still sustained a moral injury, or who were not religious and still sustained a moral injury. Of course, that is a lot of content for one book!
It’s great to see authors like those of “Soul Repair” take an interest in military topics. I hope that there will continue to be interest in moral injury among Service members in particular, with future books building on these stories and seeking out many more. I’d love to hear more about your thoughts on this book or moral injury below!
Diana C. Dolan is a clinical psychologist serving as an evidence-based psychotherapy trainer with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
Blount, Tabatha H., Jeffrey A. Cigrang, Edna B. Foa, Haley L. Ford, and Alan L. Peterson. “Intensive Outpatient Prolonged Exposure for Combat-Related PTSD: A Case Study.” Cognitive and Behavioral Practice. 21 (2014): 89-96.
Brett T. Litz, Nathan Stein, Eileen Delaney, Leslie Lebowitz, William P. Nash, Caroline Silva, and Shira Maguen. “Moral injury and moral repair in war veterans: A preliminary model and intervention strategy.” Clinical Psychology Review, 29 (2009): 695-706.
Soul Repair: Recovering from Moral Injury after War by Rita Nakashima Brock, Gabriella Lettini