Moral Injury: Another Hidden Wound of War

Vietnam vet Randy Sachs throwing medal during
1971 war protest  (photo/Sheldon Ramsdell)

Often lost in the translation of war, for soldiers as well as folks back home, is that much of what goes on in a war is a moral outrage.

After a decade and more of warfare by American military forces in Iraq, Afghanistan, Pakistan and elsewhere in hot pursuit of elusive bands of armed insurgents hiding amid sprawling cities, remote villages and other gatherings of civilians, The Associated Press has unveiled another hidden wound of war—one not listed in the usual litanies of battlefield injuries and post-traumatic stress disorder (PTSD).

“With American troops at war for more than a decade, there's been an unprecedented number of studies into war zone psychology and an evolving understanding of post-traumatic stress disorder. Clinicians suspect some troops are suffering from what they call ‘moral injuries’ - wounds from having done something, or failed to stop something, that violates their moral code,” reported AP staff writer Pauline Jelinek.

“Though there may be some overlap in symptoms, moral injuries aren't what most people think of as PTSD, the nightmares and flashbacks of terrifying, life-threatening combat events. A moral injury tortures the conscience; symptoms include deep shame, guilt and rage. It's not a medical problem, and it's unclear how to treat it, says retired Col. Elspeth Ritchie, former psychiatry consultant to the Army surgeon general.”

Here’s where the US news media’s reporting on a touchy topic involving the military too often ends. But Jelinek and other AP staff members kept digging. What they found and reported is news for even military veterans who’ve been trying to follow the twists and turns of PTSD directives from government agencies:

“Dr. Brett Litz, a clinical psychologist with the Department of Veterans Affairs in Boston, sees moral injury, the loss of comrades and the terror associated with PTSD as a ‘three-legged stool’ of troop suffering. Though there's little data on moral injury, he says a study asked soldiers seeking counseling for PTSD in Texas what their main problem was; it broke down to ‘roughly a third, a third and a third’ among those with fear, those with loss issues and those with moral injury.”

The AP reporters sought out veterans who have suffered this seldom-discussed injury. 

“Lumping people into the PTSD category ‘renders soldiers automatically into mental patients instead of wounded souls,’ writes Iraq vet Tyler Boudreau, a former Marine captain and assistant operations officer to an infantry battalion.

“Boudreau resigned his commission after having questions of conscience. He wrote in the Massachusetts Review, a literary magazine, that being diagnosed with PTSD doesn't account for nontraumatic events that are morally troubling: ‘It's far too easy for people at home, particularly those not directly affected by war ... to shed a disingenuous tear for the veterans, donate a few bucks and whisk them off to the closest shrink ... out of sight and out of mind’ …"

The only problem with this startling news report is that it could have been done a decade ago, when US forces invaded Iraq in a massive assault that killed large numbers of civilians—or for that matter, four decades ago during the Vietnam war.

In 1973, however, there was no terminology, such as post-traumatic stress or moral injury, for what a generation that fought in Vietnam brought home. But many veterans raised moral issues in protests against the war's continuation, including a 1971 demonstration in Washington where hundreds of veterans hurled war medals over a crowd control fence at the Capitol building, an event widely reported in the news media.  

Here is what a Marine veteran of that war discovered and has been writing about for years in Internet postings.

“The observation that some human beings become moral casualties because of their experiences in war is not new. Historically, many societies have recognized war’s deleterious moral effects and required returning warriors to undergo elaborate atonement and purification rituals,” notes Camillo Mac Bica, who left the Marines to become a philosophy professor. “These ‘therapies’ provided the means and the opportunity to cope with the moral enormity of their actions in war.

“Tragically, the moral injuries of modern warriors, however, have been virtually ignored, overlooked, or disregarded by the conventional therapeutic community … Focusing, instead, upon stress and trauma, most moral symptoms presented by returning soldiers are either not taken seriously or assimilated under the diagnostic umbrella of Post Traumatic Stress Disorder. Consequently, the veterans receive the signal that an inability to forget, to put the war behind them, is either weakness or, perhaps worse, illness. … Unfortunately, in most cases, moral injury neither responds well to medication nor can it be rationalized away,” Bica added.

Coming home from war, he noted, “I realized that Vietnam had profoundly affected my life, that war takes its toll on body, mind and spirit. I realized as well that America had little tolerance, interest or understanding for its returning warriors. I was called a drug addict and baby killer by many in the general public and ostracized even by fellow veterans from previous wars for being a crybaby and a loser, for lacking dedication and effort, for disgracing the ‘uniform,’ ourselves and the country for contributing to what was widely regarded as America's first lost war. This realization that I was alienated and alone and that no one seemed to understand or care about what I was undergoing, made me sad at first. Soon after that sadness was replaced by anger and resentment. 

“After several years of isolation and denial, trying to avoid ‘contaminating’ friends and family and the stigma of being a Vietnam veteran, I was convinced by another vet to seek help at the Veterans Administration (VA). Almost immediately, I was assailed by VA clinicians who ‘diagnosed’ my inability to cope, alienation, nightmares, etcetera as personal inadequacy and weakness, probably due to some pre-existing condition, perhaps a personality disorder, maybe even schizophrenia. Most likely, they hypothesized, my difficulties had something to do with my mother being overweight or my being toilet-trained too early. What was peculiarly absent from all this analysis and testing and the ad hominem attacks, however, was any reference to the war. 

"So, I blamed myself for my weakness and my mother for her eating habits and for how she raised me, and resigned myself to the fact that, for all intents and purposes, at 25, my life was over. Was I crazy, a baby killer, a crybaby, a coward? Perhaps I was all of these. Needless to say, I wasn't very pleased with myself, with those around me, or with the fact that, other than a heavy regimen of Thorazine, what some refer to as a ‘chemical lobotomy,’ VA doctors and clinicians weren't offering much help and guidance. So, it became apparent to me that if I was going to salvage what remained of my life - and I was not at all sure healing was possible - I needed to do it myself, to come to an understanding, perhaps even an acceptance, of what I had done and what I'd become.”

The question now is how much has changed for the current crop of war veterans? If moral injury is not officially acknowledged and seriously addressed, could this account for the on-going suicide epidemic among veterans and active duty troops?

The AP’s special report doesn’t ask these questions.  Instead, it veers off track:

“Many in the armed forces view PTSD as weakness. Similarly, they feel the term ‘moral injury’ is insulting, implying an ethical failing in a force whose motto stresses honor, duty and country,” writes Jelinek, who covers the Pentagon for the AP.

“At the same time, lawyers don't like the idea of someone asking troops to incriminate themselves in war crimes — real or imagined.

“That leaves a question for troops, doctors, chaplains, lawyers and the military brass: How do you help people if they don't feel they can say what's bothering them?”

A fuller report would have added the insights of dissenting veterans like Bica, who resigned from a Marine officer’s post, signed himself out of a VA facility to study philosophy and continued over the years to ask fundamental questions.

“Acknowledging the existence of moral casualties in war demonstrates that the clinical model - pathologizing a veteran's readjustment difficulties as mental illness - is inadequate and requires further evaluation,” Bica wrote in a blog post. “On the positive side, it enhances our understanding of the war experience and its devastating effects, expands our area of concern beyond trauma and PTSD, and allows us to more adequately meet the needs of our returning servicemen and –women.”

For more information:

http://bigstory.ap.org/article/im-monster-veterans-alone-their-guilt http://www.zcommunications.org/the-invisible-wounds-of-war-by-camillo-mac-bica