Moral Injury

My uncle served in the United States Army during the Vietnam War. He was boots on the ground in country, getting shot at and exposed to hellish conditions. He was exposed to the horrific compound Agent Orange, which ultimately led to non-cancerous masses on the back of his lungs, diabetes, and kidney failure. He was unable to recover. That, of course, was only the physical aspect of his injuries. Certainly, we are all familiar with psychological injuries. We’re particularly acquainted with post-traumatic stress disorder (PTSD). What you might not be familiar with is the extent to which combat veterans are making the fatal decision to end their own lives.

6,500 former military personnel killed themselves in 2012. In 2013, the United States Department of Veterans Affairs released a study that covered suicides from 1999 to 2010, which showed that roughly 22 veterans were committing suicide per day, or one every 65 minutes. Some sources suggest that this rate may be under-counting suicides. A recent analysis found a suicide rate among veterans of about 30 per 100,000 population per year, compared with the civilian rate of 14 per 100,000. However, the comparison was not adjusted for age and sex.

A study published in the Cleveland Clinic Journal of Medicine found that combat veterans are not only more likely to have suicidal ideation, often associated with PTSD and depression, but they are more likely to act on a suicidal plan. Especially since veterans may be less likely to seek help from a mental health professional, non-mental-health physicians are in a key position to screen for PTSD, depression, and suicidal ideation in these patients. The same study also found that in veterans with PTSD related to combat experience, combat-related guilt may be a significant predictor of suicidal ideation and attempts.

The statistics are grim, to say the least. Veterans commit one-fifth of all suicides in America today, at the rate of about 8,000 suicides per year. In 2012, the United States lost more active-duty soldiers to suicide than to combat in Afghanistan. It was the highest number in a year (349) since the Pentagon began tracking numbers in 2001.

Defined as an anxiety disorder, PTSD is believed to be driven by intense fear, helplessness, or horror, following a traumatic event, resulting in a variety of symptoms. Perhaps the toughest group to treat for PTSD are Vietnam vets. Many complained for decades of insomnia. Many also suffered from nightmares and hypervigilance, avoided crowds, and had marital difficulties. Psychiatrists learned to give a quick PTSD diagnosis to these vets and apply the usual formula for treatment. That is, prescribe medication to blunt the fear response, recommend social support, and refer the patient for talk therapy.

A psychiatrist by the name of Jonathan Shay, also a combat veteran, began treating Vietnam vets in the 1980s. Shay said “psychological and moral injury” sustained in combat destroys trust. He also said that when the capacity for social trust is destroyed, all possibility of a flourishing human life is lost. In Shay’s book Achilles in Vietnam: Combat Trauma and the Undoing of Character, he said he was struck by one veteran’s description of himself as a “typical young American boy,” an eighteen-year-old virgin with “strong religious beliefs.” When he went to Vietnam, “I wasn’t prepared for it all.” He found that it was “all evil…I look back, I look back today, and I’m horrified at what I turned in to. What I was. What I did.”

Treatment personnel noted that they had been trained to focus on the soldier’s fear. But these veterans were not talking about fear. They were talking about right and wrong. For those with severe long-standing PTSD, the problem was often a combination of fear and guilt and shame. Those potent emotions came not only from what they had witnessed, but also from their own actions in the morally confusing situations of modern combat. Michael Yandell, a veteran, wrote for The Christian Century earlier this year. He said, “For me, moral injury describes my disillusionment, the erosion of my sense of place in the world. The spiritual and emotional foundations of the world disappeared and made it impossible to sleep the sleep of the just. Even though I was part of a war that was much bigger than me, I still feel personally responsible for its consequences. I have a feeling of intense betrayal, and the betrayer and the betrayed are the same person: my very self.”

Soldiers face impossible moral situations in combat, of “the real stakes for people having to make these decisions.” Interestingly, a group of psychiatrists at Duke University coined the term “post-Vietnam syndrome” in 1972. The syndrome was marked by alienation, rage, feelings of betrayal by military leadership and the country itself, and an inability to give and accept love. These are all “deeply moral categories.” But their moral resonance had been lost in the systemization of PTSD and the nearly thirty years of research that followed.

Eventually, moral injury became another way of understanding combat trauma. Moral injury occurs when a soldier is exposed to or partakes in acts that transgress deeply held moral beliefs and expectations. While traumatic events and atrocities can cause moral injury, so too can more subtle acts that transgress a moral code.

Here’s the exciting part. At the heart of the Gospel is a narrative of creation, brokenness, redemption and reconciliation, a “new creation.” In Jesus Christ, we have a paradigm of mental health and flourishing. After all, Jesus was once rumored to suffer from mental illness. Mark 3:21 says, “And when his friends heard of it, they went out to lay hold on him: for they said, ‘He is beside himself.’” Christ certainly endured physical and mental anguish. The Church has language and practices to foster healing for veterans, such as lament, confession, and reconciliation. All of these allow us to “listen, reflect, bear, and grieve” with our veterans.

War, even when justified, is always a tragic manifestation of human brokenness. Churches and faith-related organizations have launched programs in recent years to better care for veterans’ mental and spiritual health. It is an important finding that our veterans are suffering from moral injury. Just on its face, it seems such an injury cannot solely be treated with medication and talk therapy. One thing though: moral injury is really a rediscovery of an older set of truths. The Church has a long history of ministry to and by veterans. Now the Church needs to find “creative and faithful ways” to walk with people suffering from a range of mental health issues.

So, in the meantime, what can we do when we encounter a veteran who has returned from combat and is struggling? If there’s one thing combat veterans hate, it’s the question, “Did you kill anyone?” It’s best simply to ask a veteran what their deployments were like, keeping in mind that people feel differently about their time in the service. The most effective approach is to be human and work on friendship. The Church has the opportunity to dress the wounds of each war-torn soul among us. Good mental healthcare is a necessary and valuable part of that work. But if we seek the full flourishing of those who have been impacted by war, the Church has an irreplaceable role to play. It is time to realize that combat veterans suffer not only on an emotional and physical level, but also on a spiritual and moral level. It would seem to me that this is the piece that has been missing from our therapeutic work with soldiers suffering from PTSD.

May God bless the men and women of our armed forces.

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One thought on “Moral Injury

  1. What a powerful article. This sentence, which you quoted: “I have a feeling of intense betrayal, and the betrayer and the betrayed are the same person: my very self.” illuminated a/the deep core of what people go through that enabled me to better understand. I never read Mark 3:21 in that way but of course Jesus would experience those things we experience or else he’d be criticized for not being able to understand what we’re going through. Understanding is the wisdom of God’s holy people. Thank you for writing.

    Like

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