Battleland

Moral Injury: “A Profound Sense of Alienation and Abject Shame”

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After more than a decade of war, post-traumatic stress disorder – PTSD — is unfortunately a too-familiar term. It is recognized in the Diagnostic and Statistical Manual (DSM) of mental disorders – the Bible of mental-health providers — and its definition has been updated recently.

The term “moral injury” is less well-known (amazingly, it even lacks a Wikipedia entry, although it has surfaced on Battleland, including here and here).
Moral injury is also commonly associated as a consequence of war. It is related to PTSD, but is not a defined medical condition.

Although discussed and defined by psychiatrists including Brett Litz, Bill Nash and Jonathan Shay, it is not yet part of the common lexicon of therapists, or the general public.

I am writing about it because I think that it is an important concept to help understand the experiences of our service members.

Moral injury is stress resulting from perpetrating, or merely witnessing, acts — or failures to act — that transgress deeply held, communally shared moral beliefs and expectations, writes Bill Nash in the enclosed article.

Moral injury arises when a service member cannot reconcile what he has done, or experienced, in war with his worldview of him or herself prior to war. Commonly this involves killing, especially when the slain are non-combatants, often women or children.

Especially troubling to the psyche is when the service member enjoyed the act of killing. Commonly secrecy and shame accompany an internal conflict. War crimes may also give rise to a corrosive seepage into the soul.

Why is the distinction between PTSD and this so-called moral injury important?

More and more, therapists are finding that these psychological injuries of war must be treated differently. Medications and exposure therapy, the gold standards for treatment of PTSD, do not work by themselves for shame and guilt.

What does work?

We do not yet know. What I hear from my therapist colleagues is about letting the service member tell their story in a way and in a place that they will not be judged. This may be with other combat-hardened veterans, or with a chaplain or therapist that they trust.

One of these therapists, Michael Castellana from the Oasis program in San Diego, wrote in an e-mail:

…what we are calling “moral injury” (moral exile serves to describe not only the initial “injury” but the process that ensues afterward), has everything to do with the darkness that warriors enter into, which altogether changes the context and belief systems that surround that warrior at some point afterward. Simply stated: It is the unspeakable part of war and is so utterly repugnant to most people, that it is pushed so far out of awareness, leaving the men and women I work with (and others as well, most likely) alone.

Innumerable times in my career, Marines have uttered the phrase – “we’ve never talked about it”, or “I have never told anyone this, not even the guy who was with me”…It causes such a profound sense of alienation and abject shame that our service members feel and believe about themselves that, in spite of themselves it seems, they are lost to the rest of time and forever exiled from any sense of community for their actions/inactions.

I am humbled by the lengths to which humans will go to survive, including taking part in a membership in combat; in a contract that they haven’t had the time to read all the fine print before signing, that will forever afterward condemn them to what they oftentimes find as a barren, forlorn and unforgiving existence. It is no wonder that suicide is so highly correlated with this thing we call “moral injury.”
It’s why I do this work. In its purest sense, we are saving lives, by being willing to listen to them without condemning them and bear witness to their truth; to help to shed some precious light, and a warm, compassionate hand out of their darkness.

As many of our returning Soldiers and Marines struggle to make sense of their repeated exposure to—and participation in—carnage and death, we need to be able to have therapists and chaplains and police officers and judges who can help them through such dark places.

7 comments
JohnMccrillis
JohnMccrillis

Moral injury? I'll show you moral injury: everytime I hear this Jonathan pollard situation come up they should have executed him. Least not forget ol Bill Clinton pardening Deutze now wouldent that be something if the CIA went public with what he was giving his mossad buddies on his unsecure computer

regbah
regbah like.author.displayName like.author.displayName 2 Like

As a VA psychiatrist and a soldier who also has numerous friends who are combat veterans, I would agree that we need to look at the spiritual component, that the PTSD of creating harm is different from the PTSD of receiving harm. Far too many of my veterans have some to view themselves as "monsters," and thus to seek to destroy themselves, not get help. I have also hear many speak of an additional source of guilt feelings when they are unable to protect the troops for whom they are responsible. People say that soldiers love each other like brothers, but I would compare it much more to how mothers love their children. As a comparison, I would ask every parent to imagine driving their children around town. There is a terrible accident, but the parent survives. How many children is it "acceptable" to lose? 

MartiWilliams
MartiWilliams

@regbah Thank you for your insightful words. I worked in psychiatry as a nurse for many years and saw some of the same feelings in my patients.

BrianStephens
BrianStephens like.author.displayName 1 Like

What about those of the American Armed Forces who were sent to work in Guantanamo Bay prison camp? In some cases young and inexperienced in the ways olf the world. They have already been brutalised by thir boot camp training. What must be going through the minds of the more thoughtful of them when they see people incarcerated for years without charge? The situation must revolt them and make them feel guilty at being forced to take part in a dehumanising and inhumane process. Not for nothing are they debriefed after a spell in the most infamous prison in the itherwisew civilised world. In addition they are told not to discuss the evil place. Is that helpful to anyone with moral sensivity?

MatthewHarris-Gloyer
MatthewHarris-Gloyer like.author.displayName like.author.displayName 2 Like

Important stuff here.  Great lay-persons definition of Moral Injury, which is totally different from PTSD.  Soldiers and sailors are more likely than civilians to experience moral injury, but civilians may experience it also, as the bombings at the Boston marathon may prove.

MartiWilliams
MartiWilliams like.author.displayName 1 Like

I am glad to see this article. I think it will help others come to grips with the hurting that war causes. Giving it a name and what it entails can be a way of helping others heal.

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