What does it mean that we humans can suffer a moral injury? In this materialistic culture it seems almost a duty to “get away with” what we can. Generally, we don’t spend a lot of time agonizing over questions of conscience. We are more likely concerned with: Does it work for me? Is it legal, and, if not, will I get caught? Many psychologists feel the conscience can interfere with our modern lives but contributes nothing.
Broadly, American society tends to downplay morality in favor of “rational self-interest.” Morality confines and expands us by forcing us to consider our relationships with others. It’s easy to narrow the factors that play into our rational self-interest to exclude morality, dispensing with the need to consider the other. It seems to place us in our own driver’s seat. Yet, looked at from another angle, rational self-interest also leaves us isolated and subject to the smallnesses of our nature, our acquisitiveness, and our fears.
But morality nevertheless remains a foundation of our human character. Ignoring it doesn’t make it go away. As we have seen, keld bites back, even when society—or military training—has conditioned us to set it aside. Remember, killing means a higher risk of suicidal ideation. How does that work with rational self-interest? Morality is real. It’s part of us.
Moral injury, sometimes called military moral injury and sometimes soul injury is a cousin to PTSD and PITS. A marine in Vietnam used the term in his journals. Jonathan Shay, MD, used moral injury to describe veterans’ experiences which fell outside physiological and psychological categories and those that involved betrayal by superiors or authority figures.
Shira Maguen, a researcher and clinician at the San Francisco VA hospital, defines moral injury as, “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”
Brock and Lettini report one veteran describing, “his PTSD (as) a breach of trust with the world. Moral injury, however, is the violation of a moral agreement he had with his own internal world, his moral identity.”
As its name indicates, and unlike PTSD and PITS, moral injury is not a psychological injury subject to psychological treatment.
The same authors wrote, “Veterans with moral injury have souls in anguish, not a psychological disorder. Feelings of guilt, shame, and contrition were once considered the feelings of a normal ethical person. However, secular approaches tend to view them as psychological neuroses or disorders that inhibited individual self-actualization and interfere with “authentic” feelings and urges. Yet, many veterans do not believe their moral struggles are psychological illnesses needing treatment. Instead, they experience their feelings as a profound spiritual crisis that has changed them, perhaps beyond repair.”
Traditional psychotherapy does not address the veteran’s “bad conscience” or “bad faith,” the underlying sense of having betrayed what you ought to have been. That you have made your life a lie. Nor does ordinary therapy help the veteran deal with “the world’s pain.” Peter Marin, the essayist, points out that moral injury “deprives us of a sense of a habitable world and trustworthy human connections, resulting in attitude of ‘it don’t mean nothin’.”
Morals are personal, intrinsic to living as a social being, as well as shared and received (familial, cultural, societal and legal) convictions about how to behave.
Keld is part of our moral structure.
Like PTSD, moral injury can be sustained by soldiers doing exactly what the chain of command and society trained them to do. Moral injury can be sustained by soldiers doing their job.
Symptoms widely associated with moral injury include guilt, shame, a loss of trust (in self, others, or God), feelings of powerlessness or hopelessness, depression, anxiety, anhedonia, anger, reexperiencing the moral conflict, and self-destructive behaviors (suicidal ideation, substance abuse, high-risk behavior, the sabotaging of close relationships).
Moral injury is associated with and nearly as common as PTSD. In one study, 90 percent of veterans with PTSD presented with at least 1 severe (9 on a scale of 10) symptom of moral injury. Nearly 60 percent presented 5 or more severe symptoms.
Veterans describe experiencing moral injury:
“People want to say thank you for your service, wave a flag…but you’re left with these experiences that leave you feeling deeply shameful... I burned through any relationship in my life with anybody who loved me…I have this feeling in my gut that something really bad is going to happen…the ceiling fall in…God’s shoe was going to fall on me. I can’t breathe…your life is hanging by a thread…it’s my responsibility to address the root of these feelings.”
He says, “It’s my responsibility.”
“I was a helicopter door-gunner…All I want now is to forget the look on their faces as we shot them down…to forget what death spasms look like, to forget what it feels like when your hooch is blown apart. They may suffer the defeat, but I’ll never forget my pleasure in killing my first 16-year old ‘Commie for Christ.’ I carried out the orders. I carried the guns.” (Italics in original.)
He says, “I carried out the orders.”
“I shouldn’t have gone along with it. I should have been more ironclad in my beliefs and I was disgusted with myself for not standing up for what I believed in.”
He says, “I shouldn’t have gone along with it.”
Kevin Powers, veteran and novelist, describes the feelings in his fiction as, “like you have bottomed out in your spirit but a deeper hole is being dug because everybody is so fucking happy to see you, the murderer, the fucking accomplice, the at-bare-minimum bearer of some fucking responsibility, and everyone wants to slap you on the back and you start to want to burn the whole goddamn country down, you want to burn every goddamn yellow ribbon in sight, and you can’t explain it but it’s just, like, Fuck you, but then you signed up to go so it’s all your fault, really, because you went on purpose, so you are in the end doubly fucked, so why not just find a spot and curl up and die…”
One researcher, Harris, found, “When PTSD is co-morbid with…moral injury, the disorder tends to be more severe, and the course of therapy needed for recovery is longer. Furthermore, among veterans with PTSD, those experiencing spiritual distress or moral injury are at a higher risk for suicide. Mental health outcomes are worse for individuals who lose their faith in the context of trauma, and treatment is less effective. …Have more difficulty with intimate relationships.”
Peter Marin wrote, “Our great therapeutic dream in America is that the past is escapable, that suffering can be avoided, that happiness is always possible, and that insight inevitably leads to joy. But life’s lessons—so much more apparent in literature than in therapy—teach us something else again, something that is both true of, and applicable to, the experience of the vets. Try as they do to escape it, the past pursues them; the closer they come to the truth of their acts, the more troubled they are, the more apart they find themselves, and the more tragic becomes their view of life.”
Some discover a frightening part of themselves. Purcell notes:
“The most troubling disruption of self described by participants involved their confronting a ‘dark side’ of themselves—a side that was variously described as a ‘beast,’ an ‘animal,’ a ‘savage,’ and a ‘monster.’ More than half of the focus group participants described confronting a part of themselves that they did not know existed before war, particularly before they participated in killing or harming others.”
As personal as those demons may be, one veteran said, “What’s most useful about the term “Moral Injury” is that it takes the problem out of the hands of the mental health profession and the military and attempts to place it where it belongs—in society, in the community, and in the family—precisely where moral questions should be posed and wrangled with. It transforms ‘patients’ back into citizens and ‘diagnoses’ into dialogue.”
And though we may avoid thinking about it, or try to repress it, the violation of our conscience stays with us. It persists. It wears us down. It ages us.
The arrow of time flows in one direction only. Robert Emmet Meagher, one of the editors of the anthology War and Moral Injury, reminds us that the term “veteran” originates in the Latin vetus: “aged, old, literally old or just old before one’s time, experienced beyond one’s years, worn, worn out.”
A former soldier recalls, “Eventually, we landed in Bien Hoa. We no more than filed off the airplane when I saw all these guys standing by the side of the runway. They were going home. They were dirty and looked like they had been through hell backwards. They just kind of looked at us and shook their heads. I stood there and looked at these guys and I thought, ‘My God, these guys look like old men.’ And, they did. The oldest one in the group probably wasn’t any older than twenty-five, but from the look on his face, I would have sworn that the guy was close to fifty.”
A veteran noted, “Back in the United States, I look at people and think: ‘You have no idea what right and wrong are.’”
A fundamental problem is that moral injury does not require adjustment so much as it requires atonement.
Purcell recounts, “For the veterans who felt that something—their faith, their identity, or their sense of justice—was deeply compromised by killing, talking was an important part of doing ‘penance,’ a term invoked by more than one participant. Penance could also mean reestablishing connections with others and finding a place and a purpose within the community. To do this, some veterans turned to community service and volunteered to help people in need.”
This pain—that is, this guilt—is not singular. As uninvolved as most of us feel, the guilt—the responsibility for war and atrocities—does not belong to the individual combat soldier alone.
Purcell again, “Participants (in a study) wondered why they were forced to carry the burden of exposure to death and responsibility for killing, whereas other people—in whose name they fought—could remain ignorant or even judgmental. One veteran confessed that he gets ‘so angry at times that people think they’re exempt from…you don’t have to experience death because we’re over here.’ This sentiment was shared by others….”
As one veteran said: “I don’t need other people to experience my pain. I need other people to understand that they are complicit in my pain. I can hold my pain myself, but other people need to understand that they have part in causing it.”
How are we complicit in his pain? What have we done—or not done—to cause his pain? What have we not considered? What have we forgotten?
Lifton, one of the psychiatrists we met who worked with Vietnam veterans, wrote: “In earlier work, I found that survivors of the Hiroshima holocaust experienced what I described as ‘a vast breakdown of faith in the larger human matrix supporting each individual life, and therefore a loss of faith (or trust) in the structure of existence.’ The same is true not only for large numbers of Vietnam veterans but, perhaps in more indirect and muted ways, for Americans in general…a sense that the killing and dying done in their name cannot be placed within a meaningful system of symbols, cannot be convincingly formulated. The result is a widespread if, again, vague feeling of lost integrity at times approaching moral-psychological disintegration.”
Supporting our troops means not only hoping and praying they survive unwounded, but hoping and praying they don’t kill anyone.
Next week: Combat veterans come home.
This post is in part based upon a work in progress, Haunted: War and the Trauma of Killing by Edward J. Santella
Sources:
Tyler Boudreau, “The Morally Injured,” in Meagher and Pryer, War and Moral Injury, 55.
Rita Nakashima Brock and Gabriella Lettini, Soul Repair: Recovering from Moral Injury after War. (Boston: Beacon Press, 2012).
Joseph Conrad, Heart of Darkness (Oxford: Oxford University Press, 2008).
Kelly Denton-Borhaug, And Then Your Soul is Gone (Equinox: Sheffield. 2021).
Nadia Abu El-Haj, Combat Trauma: Imaginaries of War and Citizenship in post-9/11 America. (New York: Verso, 2022).
Gerald R. Giglio, Days of Decision: An Oral History of Conscientious Objectors in the Military During the Vietnam War (Trenton, New Jersey: The Broken Rifle Press, 1989).
Brandon J. Griffin et al., “Moral Injury: An Integrative Review,” Journal of Traumatic Stress 32 (June 2019).
J. Irene Harris, Elizabeth S. Chamberlin, Brian Engdahl, Amanda Ayre, Timothy Usset, Diana Mendez, "Spiritually Integrated Interventions for PTSD and Moral Injury: a Review,” Curr Treat Options Psych (2021) 8:196–212.
Harold G. Koenig, Nagy A. Youssef, and Donna Ames, et al., ”Moral Injury and Religiosity in US Veterans With Posttraumatic Stress Disorder Symptoms,” Journal of Nervous and Mental Disorders 206, vol. 5 (May 2018): 328. DOI: 10.1097/NMD.0000000000000798.
Timothy Kudo, “On War and Redemption,” in Meagher and Pryer, War and Moral Injury.
Robert Jay Lifton, Home From the War: Vietnam Veterans: Neither Victims Nor Executioners (New York: Simon and Schuster, 1973).
Brett T. Litz, et al., “Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy,” Clinical Psychology Review 29 (2009).
Shira Maguen et al., “Impact of Killing in War: A Randomized, Controlled Pilot Trial,” Journal of Clinical Psychology 0, no. 0 (2017).
Robert Emmet Meagher, “Hope Dies Last,” in Meagher and Pryer, War and Moral Injury.
Robert Emmet Meagher and Douglas A. Pryer, eds., War and Moral Injury: A Reader (Eugene, Oregon: Cascade Books, 2018).
Kevin Powers, The Yellow Birds (New York: Little, Brown and Company, 2012), quoted in part in Kelly Denton-Borhaug, And Then Your Soul Is Gone.
Natalie Purcell et al., “Psychosocial Impact of Killing in War,” 1077. Natalie Purcell, Christopher J. Koenig, Jeane Bosch, and Shira Maguen, “Veterans’ Perspectives on the Psychosocial Impact of Killing in War,” Counseling Psychologist 44, no. 7 (2016).
Chaim F. Shatan, “The Grief of Soldiers: Vietnam Combat Veterans’ Self-Help Movement,” American Journal of Orthopsychiatry 43, no. 4 (July 1973).
Jonathan Shay, Achilles in Vietnam: Combat Trauma and the Undoing of Character (Scribner: New York, 1994).