Responding to moral injury in veterans

 

Killing, The Red Book. Copyright © 2012 Laura K Kerr, PhD.

According to the most recent study conducted by the Department of Veteran Affairs, twenty veterans a day commit suicide. Veterans account for eighteen percent of all suicides in the United States, but they are less than nine percent of the population. And it’s not just veterans returning from the Iraq and Afghanistan wars who are taking their own lives. Approximately 65 percent of all veteran suicides are by individuals fifty years and older who have had little or no exposure to the most recent conflicts.[1]

For too many veterans, serving in the military is a mental health risk. However, the diagnosis most often associated with combat, posttraumatic stress disorder, cannot sufficiently explain the increased suicide risk associated with military service. Yet the idea of moral injury can.

Moral injury has been defined as “the lasting psychological, biological, spiritual, behavioral and social impact of perpetuating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”[2] Herein, I elaborate on this definition of moral injury, identify the causes of moral injury and how it impacts veterans, provide a clinical explanation of moral injury, and share some of the efforts being made to address moral injury in the clinical setting. I will also share some skills that may help with achieving goals and working effectively if moral injury or posttraumatic stress is impacting your work habits.

More and more, veterans are writing and speaking about war as a moral injury, especially how it impacts their identities, if not their souls. I think it’s important that we hear veterans own accounts of their moral injuries, so I will be sharing their words found in memoirs, scholarly books, and articles with the hope that I will provide a robust and realistic portrayal of moral injury that resonates with your experience if you are suffering from moral injury, or will help you understand the nature of moral injury if you have a friend or family member grappling with it, or if you are supporting veterans in your educational or clinical work. You might notice that some of the quotes I share are long! And yet, as I hope to convince you, at the core of healing moral injury is the community’s willingness to listen to stories of moral injury, and the veterans’ willingness to share these stories.

I want to begin by stressing that moral injury is not a pathological reaction to war. And it is certainly not a weakness. On the contrary, moral injury is evidence of a strong moral sense of right that has been challenged by the conditions of war. It also marks the beginning of an oftentimes uncertain journey towards wholeness after being ruptured by the morally reprehensible experiences that make up war, whether it is a just war or an unjust one.

Although the term moral injury is relatively new, the idea is an old one. Throughout human history, spiritual leaders have been responsible for purifying soldiers’ souls after war. Rather than ‘training down,’ as we say today — focusing on adjustment and regulating a body rattled by traumatic stress — past societies and cultures attended to the moral needs of soldiers, and believed war had the potential to steal a soldier’s soul.

The Navajo, for instance, have a ceremony called “The Enemy Way” that takes two weeks to perform, and is believed to cure the effects of war and other encounters with death, including contact with the corpses of non-Navajo people. This ceremony is still used today to reintegrate US combat veterans back into their communities. Christians in the first millennium also spiritually rehabilitated those who participated in war. Soldiers were quarantined for at least a year and reduced to the status of followers not yet baptized. In effect, they were expected to spend a year regaining their faith.[3]

This idea that the soul needs its own rehabilitation following war has been reintroduced with the idea of moral injury. However, the term moral injury is neither religious nor spiritual in origin. Instead, it was introduced by Marine veteran and philosopher Camillo ‘Mac’ Bica to describe the agony he felt on reflection of who he had been during war and the painful self-judgment he felt for what he had done.  He wrote:

“Vietnam was the defining experience of my life. Though physical wounds may heal, the psychological, emotional, and moral injuries of war linger and fester. Vietnam forever pervades my existence, condemning me to continually relive and question the past. ‘Did I do enough?’ ‘Could I have done better?’ ‘Did I make the correct decisions?’ Inevitable concerns of those who must take life and whose decisions cause others to die.”[4]

Army Colonel and Chaplain Herm Keizer, who served as a chaplain in Vietnam, also witnessed a crisis of consciousness arising in the soldiers he ministered to.

“I noticed that my experience was different from those who were combatants, especially those who had taken life or watched innocent people be maimed or killed. I was amazed at their personal shame — not guilt — but profound, searing shame… . Many felt that they had committed a personal affront against God. My religious training helped me see that what they were confronting is what many experience as sin, and I tried to minister to their broken souls.”[5]

Moral injury goes to the heart of what our ancestors saw as the spiritual crisis caused by war and killing. And we cannot ‘train down’ soldiers from war without addressing moral injury.

Moral injury typically starts when veterans return from war, and finally have the time and energy to reflect on what happened, what they did, what they saw, how they were treated, and who they have become as a result of being part of war. As veterans begin to speak about their moral injuries, like Camillo ‘Mac’ Bica, we see that for many recovering from moral injury requires more emotional fortitude than boot camp. War pulls from the deepest parts of a soldier, forcing him or her to confront not only the nature of their own humanity, if not the very nature of humanity itself. But I believe the awards are great for those who commit to their spiritual rehabilitation following war. They have the capacity to become warriors of the heart as they learn to compassionately embrace all of who they are — the soldier and the human being — and are great teachers for all of us, especially other veterans, about how to safeguard our souls and recover them when they have been lost.

You may not believe in a god or gods, and thus the term ‘soul’ might feel irrelevant or even feel a bit off-putting. So I want to share a definition of soul that is non-religious and which provides a good foundation for thinking about moral injury. This definition of soul comes from the late Jungian analyst James Hillman who saw the term soul as having three particular meanings:

“First, ‘soul’ refers to the deepening of events into experiences; second, the significance soul makes possible, whether in love or in religious concern, derives from its special relation with death. And third, by ‘soul’ I mean the imaginative possibility in our natures, the experiencing through reflective speculation, dream, image, and fantasy—that mode which recognizes all realities as primarily symbolic or metaphorical.”[6]

Hillman’s definition of soul covers a lot of ground! Fortunately, we don’t need all three meanings to understand moral injury. I think Hillman’s second meaning of soul — as part of the self that lives beyond death, or experiences eternal love  — and thus the idea of soul associated with eternity, is the least relevant to moral injury. The other two definitions of soul Hillman provided — the deepening of events into experiences and that imaginative part of human nature that takes up so much of our inner life — are central to the experience of moral injury. With these two definitions of soul we identify how we all regularly turn inward, often to an imaginal state of reverie, in our attempts to make meaning of the events in our lives, to reflect on the past and anticipate the future, and to determine who we are and our worth as human beings. And when this imaginal state is overrun with images and memories of death and destruction, and feelings of shame, survivor’s guilt, or the rage of betrayal, as those suffering from moral injury regularly experience, we lose not only the possibility of an inner world of reprieve from the harshness or banality of reality, we also have difficulty finding hope for the future or seeing the beauty in our lives or the value in ourselves. I would also like to highlight that the notion of soul has a long history of representing the experience of feeling deeply interconnected with others and having the capacity to transcend aloneness. To say that one has lost one’s soul is also to speak of profound alienation.

The Origins of Moral Injury

A core outcome of moral injury is the loss of trust in oneself or others that fuels the spiral into negativity and alienation. Depending on the cause of the moral injury, humanity itself can even begin to appear corrupt. This loss of trust, or faith, in oneself or others is central to the definition of moral injury and distinguishes moral injury from PTSD. Whereas PTSD is the experience of a loss of safety, moral injury is the experience of a loss of trust.[7] I’ll further discuss moral injury and PTSD in a moment, but first let’s look more closely at the events that contribute to moral injury.

There are several types of events that can lead to moral injury, including feeling betrayed by leadership, peers, and trusted civilians, as well as betraying one’s own moral standards; involvement in or witnessing disproportionate violence, such as mistreatment of the enemy and acts of revenge; involvement in or witnessing the mistreatment of civilians, such as assault or destroying personal property; and involvement in or witnessing within-rank violence, such as military sexual trauma, friendly fire, and fragging, which is the deliberate attempt to kill a fellow soldier.[8]  However, killing, whether of a combatant, fellow soldier, or a civilian, is the greatest predictor of moral injury.

These events that cause moral injury are often divided into three categories: experiencing betrayal, transgressions committed by others, and transgressions committed by oneself. Looking at the first category, experiencing betrayal, for some, feeling betrayed far outweighs the emotional turmoil of battle. For example, Army Major Jeffrey Hall said about his two deployments to Iraq:

“You have to understand. My PTS [posttraumatic stress] had everything to do with moral injury. It was not from killing, or seeing bodies severed, or blown up. It was from betrayal, from moral betrayal….”[9]

Major Hall experienced moral injury when his commanding officer gave orders that disregarded the dignity of the civilians Major Hall was tasked to take care of, which involved respectfully burying the bodies of their family members killed in crossfire. Major Hall’s inability to honorably respond to their loss because of bureaucratic rules and apathetic leaders caused him to feel more trapped and helpless than enemy fire.[10]
Some, like Camillo ‘Mac’ Bica, felt betrayed by the entire enterprise of war:

“We are the victims of politicians’ hypocrisy, the scapegoats for the inevitable affront to the national conscience, and the sacrificial lambs sent to slaughter in retribution for our collective guilt and inadequacies. In fact, no one knows the sacrilege of war better than we who must fight it and then have to live with the memories of what we have done and what we have become.”[11]

The second category of moral injury is transgressions committed by others, thus witnessing someone else engage in acts that are perceived as gross moral violations. For instance, take the case of Dweylon, who served in Iraq doing intel for a Patriot missile unit. As relayed by Rita Nakashima Brock and Gabriella Lettini in their wonderful book Soul Repair: Recovering from Moral Injury after War:

“In his role of organizing communications, he delivered orders to officers who vastly outranked him and provided crucial information to commanders on the frontline. Not wanting to be a weak link in his unit, he worked sixteen-hour days and did his very best to help his unit stay safe. He believes that, though he never had to fire a weapon and kill someone, he is as morally culpable in killing innocent people as those who did. His efforts helped his comrades do their job better and stay alive. He also knows that he does not understand the personal cost of actual killing, but accepts that his role in an immoral war was the same as those who did the killing.”[12]

Dweylon himself remarked:

“Wearing that uniform, carrying my rifle, and doing what we did is not something I am proud of. I was representing one of the biggest purveyors of violence in the world, the U.S., a country that was founded on violence. I love my country, but no one should be proud of an unnecessary war. There were so many people who got killed and didn’t need to get killed, a child and his mother who got up one morning, went out to get some water, and were shot or blown up—so many dead innocent people like that. They stay with you; you can’t shake them off or ignore them.”[13]

The third category of moral injury involves transgressions committed by oneself, such as killing another human being. As Vietnam Veteran Karl Marlantes wrote in his powerful memoir What It Is Like To Go To War, “Killing someone will affect you. Part of you will think you’ve done something wrong. It’s drilled in from babyhood.”[14] .” As Marlantes observed, war challenges the basic belief system that governs civilian life. Basic ideas, whether they are true or not, like “people are generally good,” “bad things only happen to bad people,” or “people get what they deserve” can be rendered meaningless by exposure to war. After killing another person, even if justified by the values of the military and the rules governing war, many no longer can see themselves as good or deserving of goodness and feel cut off from the civilian world.  Timothy Kudo, a Marine captain in Iraq and Afghanistan, wrote the following about killing:

“War makes us killers. We must confront this horror directly if we’re honest about the true costs of war …. I’m no longer the ‘good’ person I once thought I was. There’s nothing that can change that; it’s impossible to forget what happened, and the only people who can forgive me are dead.”[15]

Of these three types of transgressions — betrayal, transgressions committed by others, and transgressions committed by oneself — transgressions committed by self and others have the highest correlation with suicide attempts. Furthermore, of all the transgressions, killing another person in war is the greatest predictor that a veteran will take his or her own life.

As mentioned, the suicide rate has been devastatingly high for veterans, with 20 veterans taking their own lives each day, and moral injury is seen as playing a central role. As Captain Josh Mantz who served in the Iraq War claimed: “It’s the moral injury over time that really kills people. Soldiers lose their identity. They don’t understand who they are anymore.”[16]  A 2016 survey of veterans seen in an outpatient clinic for posttraumatic stress disorder and substance use also revealed a high correlation between religious and spiritual struggles and increased suicide risk.[17]

One possible reason for the high number of suicides has been the training of soldiers for what is called “reflexive fire.”[18] In World War II it was discovered that nearly 75 percent of soldiers would not fire directly at the enemy, even when their own lives were threatened. In response, the military changed how it trained soldiers so they became conditioned to shoot before thinking — so called reflexive fire training, which has greatly increased the odds that soldiers will fire their weapons at someone over 90 percent of the time. Yet as Major Pete Kilner concedes: “The problem with reflexive fire training is that it does bypass, in some sense, [the soldiers’] moral decision-making process.”[19]

The changing conditions of war — that combat often happens in communities rather than isolated battlefields — has also increased the likelihood soldiers will not only kill someone during war, but that who they kill is as likely to be a civilian as an enemy combatant. Because there are no clearly defined battle lines, every situation can pose a threat to survival, including contact with civilians who are sometimes used as shields by insurgents. As Block and Lettini shared, “Many veterans recount with anguish stories about shooting reflexively at unarmed civilians in a split second without making a conscious decision to take a life.[20]”

Moral injuries of war are exacerbated by the lack of sufficient and appropriate opportunities to reintegrate into civilian life, including lack of time to decompress with other veterans. This is a particularly precarious situation for the reservists and National Guard troops who are more likely to be isolated from other veterans and resources such as the VA and military bases where they could find companions who share their experiences. In fact, 70 percent of the veterans who commit suicide did not regularly seek supportive services within the Veterans Administration.[21]

Many have also accused the military of failing to adequately attend to the psychological effects of war on soldiers. As anti-war activist and deserter Camilo Ernesto Mejia commented:

“A twenty-minute session centering on the admonition Don’t commit suicide doesn’t do much to ease the anguish of a soldier dealing with the horror, for instance, of having killed a child, just as a group session with a combat stress team isn’t much help if your life is at risk twenty-four hours a day.”[22]

Moral injury usually starts when the intensity of war begins to wear off, and the juxtaposition of civilian life with memories of war stirs negative self-judgment of the beliefs and actions that made surviving war possible. Nakashima Block and Lettini described this experience in painful detail:

“When the narcotic emotional intensity and tight camaraderie of war are gone, withdrawal can be intense. As memory and reflection deepen, negative self-judgments can torment a soul for a lifetime. Moral injury destroys meaning and forsakes noble cause. It sinks warriors into states of silent, solitary suffering, where bonds of intimacy and care seem impossible. Its torments to the soul can make death a mercy.”[23]

Even when veterans have other veterans to talk with, their dynamics often must change before they can have the types of conversations that support recovering from moral injury. According to Dweylon:

“I was with soldiers in Iraq who didn’t have close family ties, and they became much more emotionally attached to other soldiers. But fighting together is a different kind of relationship than having someone to talk to about what you are going through. I had friends at home I could talk to, but I didn’t talk to other soldiers about my feelings. There’s an unspoken rule that you don’t show weakness or emotions like crying to other soldiers. We are trained to bottle them up because if you lose your cool in battle for even one second, people can get killed.”[24]

Soldiers also need loving family and friends to help them make sense of what happened, and who they were during war, in order to discover who they can now become. All of us need others to help us make sense of what we imagine about ourselves and hold silently within. Through relationships we verify that we actually are the persons we imagine ourselves to be. Identity construction is not a private act, but rather requires others to confirm or deny our ideas about ourselves. Much as the late psychologist Jerome Bruner wrote,“Don’t we, too, have to tell the event in order to find out whether, after all, ‘this is the kind of person I really mean to be’?”[25]

Yet too often silence meets talk of killing and other actions that contribute to moral injury. Civilians often don’t want to hear about the realities of war, and feelings of guilt and shame can keep veterans from sharing what led to their moral injuries. The silence is thus imposed by both veterans and society, compounding veterans’ feelings of alienation, shame, and guilt. Karl Marlantes saw the situation this way:

“… the problem is that the veterans’ experiences and feelings remain quarantined from their families and communities. They go to the dark bar at the Legion Club, where children and nonveterans are not allowed. They disappear once a week into the VA outpatient clinic to be ‘cured’. They aren’t talking to friends and family; they’re talking to bar buddies and therapists.”[26]

Recovery from war and moral injury requires a collective effort. Ideally, families and friends of veterans and soldiers have opportunities to learn about the types of events that cause moral injury and the signs that their loved one is suffering from it. Ideally, they have opportunities to learn and practice nonjudgmental listening skills so they can help their loved ones make sense of who they are after war, witnessing that the depth of their humanity extends far beyond the events that led to moral injury. And ideally, families and friends of veterans also learn how to take care of themselves when feeling overwhelmed by the realities of war, and have places where they can seek support. Although it’s not easy listening to stories of killing and destruction, they need to be told and heard. As Karl Marlantes witnessed, listening to stories of war can be difficult, but necessary:

“What do we do when, in an honest moment, the former pilot looks right into your eyes, completely vulnerable, and says in a near whisper, “I loved it. I lit up the entire fucking valley.” One honest reaction is to be appalled. The chances are pretty good that if he lit up the entire fucking valley he probably maimed and killed a lot of innocent people along with the ones who were trying to kill him and he most certainly did vast damage to the natural habitat. But should we condemn him for speaking the truth? At one level, and one he’s admitting, he certainly loved it. So did I. At another level he did what his society had asked him to do, and he did so with skill, courage, and even élan. Should that same society now cut him off at the throat or, worse, at the balls? The appropriate response is to get him to keep talking about it. It may just be a bit shocking to find your friend has a wild and savage side that did a lot of harm. And it won’t hurt him to find out that you think he did something very harmful and destructive, as long as at the same time he finds out that you won’t love him any less for it. This is his great fear, that he won’t be accepted back in. So he joins the conspiracy of silence. So do we all.”[27]

Responding to Moral Injury

Returning veterans with religious affiliations may seek their churches, synagogues, mosques, and sanghas to support them in their moral recovery, just as humans have done for centuries. However, some returning veterans may feel cut off from their faith because of what happened in war. They may feel they don’t deserve forgiveness, or that their god somehow deserted them. These veterans in particular may benefit from clinical support until they feel comfortable reconnecting with their faith. However, many veterans and military service personnel feel more comfortable speaking to chaplains and other ministers of faith, especially given the stigma associated with mental illness in the military and the effect that a diagnosis can have on an enlisted person’s career. Some researchers suggest religious leaders learn basic psychological first aid, including familiarizing themselves with the signs of PTSD and methods for regulating traumatic stress, while working with veterans to identify the kinds of services they and their families need to support readjustment to civilian life.[28] The goal is to create places of worship that can provide comprehensive care — addressing the psychological, social, and spiritual needs of returning veterans and their families. Similar approaches can be taken in educational settings, such as offering a dedicated veterans resource center where veterans, reservists, and active duty members experience a sense of community within the larger institution.

Because shame and alienation is at the core of moral injury, rejoining with the larger community is paramount for recovery. Although fellow veterans are likely to provide the greatest support, veterans also need us civilians to reach out to them and bring them back into the fold of the larger community. One of the simplest efforts that can be made is sensitively asking about their experiences – When and where did you serve? What branch did you serve in? What kind of work did you do? Unfortunately, not only are veterans’ experiences in war regularly met with silence, many relay that when they are asked, it is often because someone wants to know if they killed someone. Although killing may be a central cause of moral injury, when discussing such topics great sensitivity is necessary, especially as many veterans anticipate being scapegoated and further alienated if they answer honestly. Since moral injury involves a loss of trust, attention to respecting personal integrity is vital when broaching topics that may be related to moral injury.

For clinicians, a Moral Injury Event Scale exists as well as a Moral Injury Questionnaire. Both can be used to evaluate for the presence of moral injury as well as initiate conversations about experiences in war. The Event Scale includes statements such as “I saw things that were morally wrong”; “I am troubled by having witnessed others’ immoral acts”; and “I acted in ways that violated my own moral code or values.”[29] However, discussions of moral injurious events cannot be assuaged by what the authors of Soul Repair called “premature forgiveness.” They assert:

“Premature forgiveness may be cathartic and offer emotional relief, but receiving such forgiveness requires amnesia about the full extent of harm that war inflicts. Facile forgiveness interferes with veterans facing the truth of what they did. It may offer anesthesia for the pain of moral injury, but premature forgiveness can create an addiction to relief, and it can reinforce a need to tell horror stories, enact guilt, and solicit forgiveness. This cycle relieves moral responsibility temporarily instead of building the lifelong strength to live with it.”[30]

Below I share treatments that demonstrate how to avoid premature forgiveness while contributing to recovery and growth following moral injury.

Whether support is sought in places of worship, mental health clinics, or educational institutions it helps to distinguish between PTSD and moral injury in order to best tailor services to veteran’s needs, so I want to share a basic overview of the symptoms associated with posttraumatic stress disorder and contrast them with moral injury.

PTSD is a reaction to an overwhelming event that threatened life or caused severe injury, resulting in an overall sense of lost safety. The cardinal symptoms of PTSD are nightmares, flashbacks and intrusive memories of the traumatic event. When triggered by reminders of the trauma, defensive reactions such as hyperarousal, numbing, or avoidance are activated, making it difficult to get on with daily living. The emotions often aroused by PTSD include, fear, if not terror, and helplessness.

In contrast, moral injury causes an inner turmoil in the imaginal state Hillman associated with the soul, and includes feelings of shame, guilt, or worthlessness for the perceived moral transgressions. Like PTSD, moral injury can also involve intrusive memories, avoidance, and numbing. Yet moral injury is thought to differ in the amount of self-sabotaging behaviors that occur, including deliberately sabotaging relationships, engaging in self-harm, and attempting suicide.[31] PTSD and moral injury are frequently both present and many of their symptoms overlap, thus the importance of understanding the signs of both when supporting veterans and soldiers.

Research into the clinical treatment of moral injury is relatively recent, although established models for the treatment of trauma are useful for thinking about the psychological consequence of moral injury, including the model of complex trauma and the model of structural dissociation. After briefly outlining these two models, I’ll share treatments currently used to address moral injury.

Complex Trauma

Some researchers and clinicians have suggested that the model of complex trauma may be a comprehensive way of looking at the impact of war on veterans.[32] This makes sense to me. The model of complex trauma addresses changes caused by prolonged and recurring traumatizing conditions, such as those that characterize war. Chronic traumatization can also lead to structural changes in the personality and increase the likelihood of self-harm, which are also more often associated with moral injury. The characteristics of environments that lead to complex trauma include: traumatic events that are random and unpredictable; the inability to escape the traumatizing conditions, causing a sense of captivity; and emotions that tend to be invalidated or cannot be expressed without fear of invalidation — all of which are observed in war.[33] Furthermore, the presence of interpersonal violence and attachment loss, such as the death of a fellow soldier, increase the likelihood of developing complex trauma.

When trauma has been chronic and unaddressed, the reactions to adapting to continual threat are numerous and include:

  • Depression
  • Irritability
  • Decreased interest in activities that used to bring pleasure
  • Numbing, either physically, emotionally, or both
  • Decreased concentration
  • Insomnia
  • Hyperarousal and/or agitation
  • Foreshortened sense of the future
  • Hopelessness
  • Amnesia
  • Intrusive memories
  • Startle response
  • Hypervigilance
  • Nightmares
  • Shame, self-hatred
  • Generalized anxiety
  • Panic attacks
  • Somatic symptoms, chronic pain
  • Substance and/or process abuse
  • Eating disorders
  • Self-destructive behaviors
  • Dissociation

As this long list suggests, the responses to chronic traumatization include many reactions not supported by the traditional definition of PTSD, and in fact include many other diagnoses found in the DSM.

Chronic traumatization also leads to structural changes in the personality that can cause a demarcation in veterans and soldiers between who they are at home and who they are in war. Veterans and soldiers can feel haunted by the need to join these often radically different senses of self. As Karl Marlantes wrote:

“Killing someone without splitting oneself from the feelings that the act engenders requires an effort of supreme consciousness that, quite frankly, is beyond most humans. Killing is what warriors do for society. Yet when they return home, society doesn’t generally acknowledge that the act it asked them to do created a deep split in their psyches, or a psychological and spiritual weight most of them will stumble beneath the rest of their lives. Warriors must learn how to integrate the experience of killing, to put the pieces of their psyches back together again. For the most part, they have been left to do this on their own.”[34]

He goes on to say:

“My problem was that for years I was unaware of the need to heal that split, and there was no one, after I returned, to point this out to me. That kid’s dark eyes would stare at me in my mind’s eye at the oddest times. I’d be driving at night and his face would appear on the windscreen. I’d be talking at work and that face with its angry snarl would suddenly overwhelm me and I’d fight to stay with the person I was talking with. I’d never been able to tell anyone what was going on inside. So I forced these images back, away, for years. I began to reintegrate that split-off part of my experience only after I actually began to imagine that kid as a kid, my kid perhaps. Then, out came this overwhelming sadness—and healing. Integrating the feelings of sadness, rage, or all of the above with the action [of killing] should be standard operating procedure for all soldiers who have killed face-to-face.”[35]

Structural Dissociation

A model that helps understand this sense of being split is the model of structural dissociation, which similar to complex trauma, identifies the core reaction to ongoing trauma as structural changes in the personality.[36] For veterans struggling with structural dissociation, part of the self is in exile as he or she avoids memories, emotions, and beliefs associated with who they were during war. As Tyler Boudreau, a soldier in Iraq, spoke of veterans at home:

“There are guys who come home from war and live fifty years without a narrative, fifty years lost. They don’t know their own story, never have, and never will. But they’re moving amidst the text every day and every long night without even realizing it …. They live inside the narrative like a cell, and their only escape is to understand its dimensions.”[37]

Structural dissociation of the personality likely takes advantage of the partitioning of the brain into left and right hemispheres in which the corpus callosum that joins the two hemispheres plays a largely inhibitory role. As a result, humans can split off awareness of emotions and traumatic memories located in the right hemisphere while the left hemisphere, as the seat of rational thought and planning, attempts to function unimpeded by unresolved traumatic memories. This splitting of the hemispheres, in a twisted sense of fate, has made possible surviving war and other conditions that are chronically traumatizing. However, recovering from trauma and moral injury requires reintegrating split off emotions, memories, and beliefs associated with the trauma in order to create the type of narrative and identity that Boudreau and Marlantes saw as necessary for overcoming the effects of war.

It’s important to acknowledge that all of us have different parts of ourselves, and memories and feelings we try to suppress, but what makes structural dissociation particularly difficult to overcome is the rigidity of the personality that occurs in response to ongoing trauma. In the model of structural dissociation, the personality is thought to be made up of different systems. When these systems are not divided by chronic traumatization, they work together in cohesive and complimentary ways to ensure survival. Two primary aspects of the personality are the action systems that contribute to daily living and the action system of defense. The action systems of daily life lead us to seek what keeps us alive and growing, such as safe attachments, companions, a mate, food, shelter, play, and exploration, while the action system of defense leads to defensive reactions to threat, such as fight, flight, freeze, submit or attachment cry. After chronic traumatization, these personality systems become less adapted to present conditions. The system of defense starts to misread benign stimuli as evidence of a threat. The personality becomes rigid, rather than adaptive, as harmless situations are repeatedly registered as threats. Getting on with daily life becomes complicated, if not exhausting, as the chronically traumatized person becomes phobic of traumatic reminders, and thus begins to withdraw from life.

The creators of structural dissociation describe the traumatized self as divided into at least two parts: the Apparently Normal Part of the Personality that takes care of day to day living by presenting a façade of normalcy; and an Emotional Part of the Personality that holds the emotions. memories, and associated beliefs split off at the time of the traumatic or morally injurious event. This distinction was first used to describe ‘shell-shocked’ soldiers in World War I by psychiatrist Charles Samuel Meyers.[38] In veterans, distinctions between the Apparently Normal Part of the Personality and the Emotional Part of the Personality have been called the “adaptive self” and the “war self,”[39] respectively.

In chronic traumatization, the Emotional Parts of the Personality organize around the defense reactions fight, flight, freeze, submit, and attachment cry. These defenses are altered by the need to endure ongoing traumatic conditions and begin to function as rigid subsystems of the personality. For example, there can be a Fight Emotional Part that when triggered tries to protect from further harm by being angry, mistrustful, destructive, devaluing, impulsive, and even suicidal. And we can expect that veterans trained in combat have a particularly robust fight part that is activated when intrusive memories threaten to break through. There may also be a Flight Emotional Part that distances from threats through ambivalence and difficulty making commitments, as well as through addictive behaviors. Furthermore, a Submit Emotional Part is associated with depression, shame, self-loathing, passivity, and getting needs met by taking care of others. There may just be one emotional part, or there may be many.

Emotions such as shame and guilt, along with pride, are also thought to make up a personality system devoted to maintaining social bonds.[40]  These emotions contribute to social belonging by maintaining attachments and social positioning. Shame and guilt are adaptive when they contribute to social engagement and motivate us to change behaviors if doing so will ensure acceptance by the group. But like defenses such as fight or flight, shame and guilt can also be split off, or dissociated, especially when there is the fear of social rejection. However, if we hide what makes us feel shameful or guilty, our need to protect ourselves may increase the likelihood of social withdrawal. We can also cause social rejection when we aggressively defend against the possibility of shame.

Splitting off emotions at the time of the moral injury — for instance, not dealing with the feelings that killing causes during the intensity of battle — and then staying silent about those experiences once back home because of fear of rejection, redoubles the likelihood that some very powerful emotions are not integrated into the rest of the personality and become habitually compartmentalized. It’s painful for anyone to regularly feel shame, guilt, and worthlessness, let alone stay engaged in relationships and community when continually flooded by these emotions. So when they come forth, as they invariably will when there is a moral injury, the tendency is to try to avoid them if that will increase the likelihood of staying socially engaged. And as Tyler Boudreau observed, decades can go by without those split off feelings and memories ever dealt with. For example, Billie Grimes-Watson shared:

I have all this guilt inside me and I want to let it out but I can’t. I want to tell my husband and family what’s going on, but I don’t. I just put on a happy face until I am alone.”[41]

Increasing Mental Energy and Efficiency

The longer structural changes in the personality endure, the more likely the associated states of emotional overwhelm, shame, and loss of identity begin to feel like the norm. These structural changes also interfere with harnessing the mental energy needed to meet goals and complete desired actions, which is especially relevant to veterans seeking an education following war.

Typically, when people think about overcoming a history of chronic traumatization they imagine confronting the memories they have avoided. Although this is an important aspect of posttraumatic growth, it’s usually not the best place to start. Rather, learning how to live productively in the present is a rewarding first step, which often involves creating safety and stability not only in the external environment, but also within the ‘internal environment’ of the mind and body. And many of us feel safe and stable when we regularly meet goals and follow through on meaningful projects, like getting a college degree. Indeed, this is often a sign that the grip of the past is beginning to subside.

The creators of the model of structural dissociation focus on improving both mental energy and mental efficiency as central aspects of recovering from chronic traumatization and living with greater awareness of present needs and goals. Actions are most adaptive when there is an optimal balance between mental energy and mental efficiency – just the right amount of energy and effort to accomplish the task at hand.

However, because of the need to keep intrusive feelings, beliefs, and memories at bay, both mental energy and mental effectiveness are diminished. This can appear as
•    Difficulties starting as well as completing goals and actions
•    Difficulties sorting through information to make a decision or chose a direction or focus
•    Impulsive actions
•    Lack of satisfaction with efforts
•    Difficulty taking breaks when involved in ongoing projects

For some, it can help to have models or methods that help them nonjudgmentally examine their inner states and either identify where difficulties arise, or use skills that help foster living in the present and in alignment with the action systems of daily living rather than the action system of defense.

For example, Ron Kurtz, the creator of the Hakomi Method, a mindfulness-based, body-focused form of psychotherapy, identified four stages that contribute to effective functioning, which have been adapted for meeting goals and completing actions. This adapted model is called the action cycle, which helps to identify inner states involved in completing actions and reaching goals. The four stages of the action cycle include:
1.    Insight into why the goal is meaningful
2.    Listening to internal responses
3.    Feeling nourished by the activity
4.    Recognizing completion

Problems with insight often involve difficulty identifying the intention, or meaning, behind actions. Without sufficient insight, it’s easy to lose interest in goals. Insight is also referred to as “knowing your why.” Sometimes something as simple as a visual reminder can help with insight. I know this helps me,  so I keep a list of my major goals framed on my desk to keep me focused on the bigger picture, which is very helpful when engaged in tasks I do not particularly enjoy.

Difficulties with internal responses towards a goal often arise when someone is cut off from authentic emotional expression, which can interfere with taking non-ambivalent action towards goals. Thus, it is especially important when working on important goals to engage in self-study and foster nonjudgmental awareness of emotions, even negative ones, and observe inner reactions to the work being done. Especially when completing a particularly onerous task, or experiencing intrusive memories and emotions, acknowledging negative emotions and practicing self-care by taking frequent breaks is a healthy way to validate and make room for difficult emotions. Acknowledging difficult emotions and making concessions for them is also important for avoiding the negative self-judgments and ‘should’ thoughts that can fuel feelings of shame and worthlessness and derail important goals.

Difficulties with nourishment occur when there is not a genuine sense of which actions contribute to a sense of accomplishment. When there are difficulties with nourishment, nonjudgmental and compassionate awareness is again important, as well as giving oneself extra time to complete tasks with an eye on learning what brings enjoyment. For example, when writing a term paper, maybe the research is the most enjoyable, but organizing the ideas into a coherent whole feel more like drudgery. Knowing how one feels about different aspects of the work supports recognizing resistances as natural, and will more likely lead to making changes in behaviors and time-management in ways that contribute to more authentic self-expression and less self-judgment, while also increasing the likelihood of completing goals.

Difficulties with completion, often arise when there is no sense that stopping to reward or replenish oneself is a deserved aspect of meeting a goal, or there may be an inability to identify what signifies that an action has reached its endpoint. Especially when people are cut off from their emotions, there is the tendency to treat life like it is a check list. Making time for relaxing, and thus feeling emotions, is not only healthy for everyone, but is the foundation for letting in emotions that have been dissociated or denied.

Using models like the action cycle is one way of bringing attention to inner states in the present moment for the purpose of reaching optimal mental energy and effectiveness.  Whatever method or model used, it is crucial to use nonjudgmental and compassionate awareness of inner states to support accepting all aspects of the self while also living with present-centered awareness. Other methods might include reviewing simple mantras that increase emotions associated with safety and thus the action systems of daily living. For example, mantras like:

• It’s okay to be vulnerable
• It’s okay to take care of my needs
• It’s okay to have fun
• It’s safe to feel
• It’s safe to rely on others
• It’s safe to be witnessed
• I can be myself and be loved

Such universal truths of safe conditions and relationships can help calm emotions and orient away from defense states. Some may experience the inevitable ‘grief of relief’ that can happen when defenses begin to be released and there is enough internal safety to acknowledge split off feelings of sadness and loss.

On my website, you can also download a free and short guide of body-based techniques for orienting towards the present and living ‘within the window of tolerance,’ which is another way of describing living in the present focused on the action systems of daily living. In this model, the action system of defense is divided into signs of hyperarousal associated with the activation of fight and flight responses, and the signs of hypoarousal associated with the submit response, and techniques are used to move from these states back ‘into’ the window of tolerance.

Treatments for Moral Injury

Recovery from chronic traumatization and moral injury is probably best thought of as an ongoing process rather than reaching an endpoint or a ‘cure’.  Veterans and soldiers suffering from moral injury especially need to establish and maintain an inner middle ground in which they can accept the past even if they cannot condone it. The harsh inner critic that sees goodness forever out of reach must be replaced with a nuanced understanding of the complexities of war and the limits of their responsibility for what occurred. Strict distinctions between good and evil must be dismantled and replaced with acceptance of the ambiguity that surrounds most human behavior. The psychiatrist Carl Gustave Jung wrote about the importance of this middle ground in his autobiography of regaining his own soul, The Red Book. He wrote:

“If the power of growth begins to cease, then the united falls into its opposites. We suspect and understand that growth needs both, and hence we keep good and evil close together. Because we know that too far into the good means the same as too far into the evil, we keep them both together.”[42]

In this quote, I don’t think Jung is referring to actions that are good or evil, but rather how we interpret the imaginal contents of soul, especially how we imagine ourselves to be. Furthermore, I don’t think it is a coincidence that he was incubating many of the ideas developed in this seminal work while serving military service during World War I.

Similar to Jung, some of the treatments currently used to address moral injury are directed towards reducing the critical, inner voice that convinces veterans and soldiers they can never be ‘good’ again. For example, the treatment Adaptive Disclosure[43] works with what Hillman described as the imaginal contents of soul. In Adaptive Disclosure, over the course of eight weekly ninety minute sessions, veterans and soldiers work towards reducing the intensity and rigidity of their memories of moral injury. This involves “imaginal exposure” to the events that led to moral injury, identifying the associated beliefs about the self and what occurred, all in the context of charged emotions that such recall inevitably causes. Participants also imagine having a conversation with the person injured or killed. Rather than that person condemning them, they imagine her or him offering compassion and forgiveness. The veteran or soldier can also imagine having similar conversations with someone they see as having moral authority, and who similarly offers compassion and forgiveness in response to the perceived moral transgressions.

Another exercise used in Adaptive Disclosure involves redistributing the blame as a way to create a more accurate portrayal of the event that led to moral injury, sharing responsibility across all the people and institutions that led to the perceived transgression. In this exercise, anyone who played a role in the circumstances leading up to the morally injurious event are listed and assigned percentages for their part in what happened. Journalist David Wood, in his terrific article, “Healing: Can We Treat Moral Injury?” described how this changes the nature of blame:

“If a Marine shot a child in combat, he might accept 30 percent of the blame. He might award the Taliban 50 percent, the child himself 5 percent and the Marine Corps 5 percent. God, perhaps, 10 percent.”[44]

Studies show Adaptive Disclosure reduces PTSD symptoms, negative self-appraisals, and depression while increasing posttraumatic growth.[45]

The San Diego Naval Medical Center offers a similar program — a moral injury/moral repair group, which helps soldiers gain a more balanced appraisal of what they did in war. One of the central goals of this program is to help veterans and soldiers see that what they did in war doesn’t define who they are or limit who they can become. Those who take part in the groups are expected to resist minimizing what veterans did during war, or giving explanations for it, yet still affirming they are not ‘evil’ because of their perceived transgressions. Thus, during group a member will share the event that caused moral injury while other members quietly listen, neither passing judgment nor excusing his or her actions , thus avoiding the “premature forgiveness” the authors of Soul Repair warned about. One participant said about the group:

“People give you space. And they got a therapy dog in there, and he comes over and wags his tail a little bit, tells you it’s OK, too, you know? Not saying it’s OK, but just to say you’re not some wicked person.”[46]

Many, however, do think they are “wicked.” Michael Castellana, one of the psychotherapists that leads the group, relayed the story of a soldier rushed by insurgents using women and children as shields, who he inevitably shot so he could stay alive:

“When he arrived home, coming off the plane, his wife handed him his new baby daughter. She put the baby in his arms and he immediately gave the baby back to her with an almost disgusted look — he almost dropped her. The thing was, his new daughter was so beautiful and perfect and pure that he didn’t want his filth to contaminate her.”[47]

To alleviate the feeling of being forever tainted by their actions during war, members of the moral injury/moral repair group take part in community service, which becomes an opportunity to witness their own goodness and experience their communities’ receptiveness to their acts of kindness. No doubt, volunteering also helps validate their belonging, reducing both alienation and shame.

Near the end of the moral injury/moral repair group, similar to Adaptive Disclosure, participants write a letter to themselves or someone compassionate and loving in their lives, such as a spouse, elder, or mentor. They use the letter to imagine sharing the actions that led to moral injury. They imagine the person’s compassionate acceptance of them, regardless of what they did. Participants are also given the option of writing a letter to a person they transgressed. Marine staff sergeant Felipe Tremillo wrote a letter to a young Afghan boy he watched trembling with shame and rage as Marines forced his family outdoors while they searched his home for weapons. Tremillo wrote in his letter: “I told him how sorry I was at how I affected his life, that he didn’t have a fair chance to have a happy life based off our actions as a unit.” About the letter Tremillo remarked “[It] wasn’t about me forgiving myself, more about accepting who I am now.”[48]

Both Adaptive Disclosure and the moral injury/moral repair group get the process of recovery started, promoting self-forgiveness and self-compassion, challenging the tendency towards all-consuming self-blame that keeps veterans alienated in guilt, shame, and feelings of worthlessness. Yet the treatment of moral injury is not seen as reaching its end point at the end of the eight weeks of Adaptive Disclosure or at the end of the eight-week moral injury/moral repair group. In fact, no one is sure how long it takes to recover from moral injury.

Most likely, rather than reaching an endpoint, recovery from moral injury requires continually investing in the attitudes and skills these programs encourage: compassionately relating to oneself, accepting the past with self-empathy, relying on community to know oneself, and committing to a purposeful life. Then, as Camilo Ernesto Mejia described his recovery from moral injury, life becomes meaningful again, possibly more than ever imagined:

“Moral injury is painful, yes, but it has also returned a sense of humanity that had been missing from my life for longer than I can remember. I have come to believe that the transformative power of moral injury cannot be found in the pursuit of our own moral balance as an end goal, but in the journey of repairing the damage we have done unto others. There is much to be learned about moral injury … But if there is one thing I am certain about, it is that in committing great wrongs against others, I committed great wrongs against myself as well. And with the certainty that it will take a lifetime to heal the injuries within me, I embark on this lifelong journey to heal the injuries of others.”[49]

As Mejia shows us, despite the psychological and spiritual devastation caused by moral injury, there is a way out. Like the Phoenix rising from the ashes, a path is also laid in the direction of one’s most compassionate self, what some might call the warrior of the heart.

References

[1] Shane, L. and P. Kime (2016, July 7). New VA study finds 20 veterans commit suicide each day. Military Times. http://www.militarytimes.com/story/veterans/2016/07/07/va-suicide-20-daily-research/86788332/ Accessed January 5, 2017.
[2] Litz B. T., S. N., Delaney E., Lebowitz L., Nash W.P., Silva C., & Maguen S. (2009). “Moral injury and moral repair in war veterans: a preliminary model ” Clinical Psychology Review.10.1016/j.cpr.2009.07.003
[3] Brock, R. N. and G. Lettini (2012). Soul Repair: Recovering from Moral Injury after War. Boston, MA, Beacon Press, p. xviii.
[4] Ibid., p. xiv
[5] Ibid., p. 26.
[6] Hillman, J. (1975). Re-Visioning psychology. New York, Harper Perennial, p. xvi.
[7] Litz B. T., S. N., Delaney E., Lebowitz L., Nash W.P., Silva C., & Maguen S. (2009). “Moral injury and moral repair in war veterans: a preliminary model ” Clinical Psychology Review.10.1016/j.cpr.2009.07.003
[8] Maguen, S. and B. Litz (2012). “Moral Injury in Veterans of War.” PTSD Research Quarterly 23(1): 1-6; Drescher, K. D., Foy, D. W., Kelly, C., Leshner, A., Schutz, K., & Litz, B. (2011). An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology, 17, 8-13. doi: 10.1177/1534765610395615
[9] Sherman, N. (2015). Afterwar: Healing the Moral Wounds of Our Soldiers. New York, NY, Oxford University Press, p. 78.
[10] Ibid, p. 79.
[11] Nakashima Brock and Lettini, 2012, p. 21.
[12] Ibid., p. 29.
[13] Ibid., pp. 59-60.
[14] Marlantes, K. (2011). What Is It Like To Go To War. New York, NY, Grove Press, p. 18.
[15] Kudo, T. (2013, January 25). I killed people in Afghanistan. Was I right or wrong? The Washington Post. https://www.washingtonpost.com/opinions/i-killed-people-in-afghanistan-was-i-right-or-wrong/2013/01/25/c0b0d5a6-60ff-11e2-b05a-605528f6b712_story.html?utm_term=.d2dfcf51f40d Accessed October 26, 2016.
[16] Sherman, 2015, p. 7.
[17] Raines, A.M.; J. Currier; E. S. McManus; J. L. Walton; M. Uddo; and F. C. Laurel (2016, Dec 12). Spiritual struggles and suicide in veterans seeking PTSD treatment. Psychological Trauma: Theory, Research, Practice, and Policy.
[18] Nakashima Block and Lettini, 2012, p. 18.
[19] Ibid.
[20] Ibid., p. xvii.
[21] Shane, L. and P. Kime (2016, July 7). New VA study finds 20 veterans commit suicide each day. Military Times. http://www.militarytimes.com/story/veterans/2016/07/07/va-suicide-20-daily-research/86788332/ Accessed January 5, 2017.
[22] Ibid., p. 60.
[23] Ibid., p. xvi.
[24] Ibid, p. 82.
[25] Bruner, J. (2002). Making Stories: Law, Literature, Life. New York, Farar, Straus and Giroux, p. 73-74.
[26] Marlantes, 2011, p. 119.
[27] Marlantes, 2011, p. 218.
[28] Drescher, K. D. and D. W. Foy (2008). “When They Come Home: Posttraumatic Stress, Moral Injury, and Spiritual Consequences for Veterans.” Reflective Practice: Formation and Supervision in Ministry 28: 85 -102.
[29] Nash, W. P.; T. L. Marino Carper; M. A. Mills; T. Au; A. Goldsmith; and B. T. Litz (2013). Psychometric Evaluation of the Moral Injury Events Scale. Military Medicine, 178, 6: 646.
[30] Nakashima Block and Lettini, 2012, p. 103.
[31] Litz et al, 2009.
[32] Worthington, E. L. and D. Langberg (2012). “Religious Considerations and Self-Forgiveness in Treating Complex Trauma and Moral Injury in Present and Former Soldiers.” Journal of Psychology & Theology 40(4): 274-288.
[33] Linehan, M. (1993). Skills Training Manual for Treating Borderline Personality Disorder. New York, Guilford Press; and Herman, 1997.; Herman, J. (1997). Trauma and Recovery: The Aftermath of Violence—from Domestic Abuse to Political Terror. New York, BasicBooks.
[34] Marlantes, 2011, p. 26.
[35] Ibid, p. 32.
[36] Hart, O. v. d., E. R. S. Nijenhuis and K. Steele (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. New York, W. W. Norton & Company, p. vii.
[37] Nakashima Brock and Lettini, 2012, p. 65.
[38] Ibid., p. 5.
[39] Ibid, p. 30.
[40] Turner, J. H. (2000). On the Origins of Human Emotions. Stanford, Stanford University Press; Hart, O. v. d., E. R. S. Nijenhuis and K. Steele (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. New York, W. W. Norton & Company.
[41] Wood, D. (2014, March 20). Healing: Can We Treat Moral Injury? The Huffington Post. http://projects.huffingtonpost.com/projects/moral-injury/healing. Accessed October 27, 2016.
[42] Jung, C. G. (2009). The Red Book: Liber Novus. New York, W. W. Norton & Co.
[43] Gray, M.J., Schoor, Y., Nash, W., Lebowitz, L., Amidon, A., Lansing, A., Maglione, M., Lang, A.J., Litz, B.T. (2012, June). Adaptive Disclosure: An Open Trial of a Novel Exposure-Based Intervention for Service Members With Combat-Related Psychological Stress Injuries. Behaivoral Therapy, 43:2, pp. 407-415.
[44] Wood, 2016.
[45] Gray et al, 2012.
[46] Wood, 2016.
[47] Ibid.
[48] Ibid.
[49] Nakashima Block and Lettini, 2012, p. 89.

 

Updated January 12, 2017.

© 2017 Laura K Kerr, PhD. All rights reserved (applies to writing and photography).