As chief medical officer at the Denver Military Entrance Processing Station, my duties involve determining the physical and psychological fitness of men and women who wish to join the armed forces. Sadly, some applicants who have previously served and wish to reenlist suffer from combat-related illnesses, injuries, and experiences that have led to post-traumatic stress disorder (PTSD). PTSD is recognized as a mental illness by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and is defined by the Department of Veterans Affairs as an anxiety disorder characterized by a spectrum of symptoms, including reliving the traumatic event, avoiding places or things that remind one of the event,feeling numb, having persistent frightening thoughts, and hyper arousability.
More recently, Dr. Jonathan Shay, clinical psychiatrist at the Veterans Administration Boston Health Care System, introduced the concept of “moral injury.”Moral injuries often co-occur with PTSD. Moral injury is not recognized by the current version of the DSM, but it is characterized by the Department of Veterans Affairs as “an act of transgression, which shatters moral and ethical expectations that are rooted in religious or spiritual beliefs, or culture-based, organizational, and group-based rules about fairness, the value of life, and so forth.” Increasing numbers of mental health workers recognize it as one antecedent of PTSD, especially in military combat environments.
Moral injuries are examples of profound trauma not to the dead but to the survivors. Paraphrasing Dr. Shay, they are caused by betrayals of what is considered ethical in our culture, ordered by someone who holds legitimate authority in our societal system, and occur in life-or-death situations. UnlikePTSD, a moral injury is a dimensional problem that damages those personal values that undergird a service member’s humanity.
Camilio E. Mejia wrote a poignant description of his own moral injury that was published by the Fellowship of Reconciliation, a nonviolent organization. Camilio joined the Army at age nineteen. Under orders, he fired his gun at a young man who was about to throw a grenade at Ramadi’s main government building in central Iraq. Even before pulling the trigger, he knew that the youth was too far away to hurt any of his group. After the shooting, Mejia repeatedly counted the bullets he’d fired and was horrified that he’d shot eleven rounds into the man. He said that for weeks after the incident his mind could not shake off the images of the young man walking and breathing, then down on the ground bloody and dead. He describes his moral injury as “the pain I inflicted upon the very core of my being when I took something I could never give back. It is a pain that redefined my life, and that not only transformed who I was, but continues to transform me.” He continued, “When I opened fire that day, I violated that law and desecrated the most sacred sanctuary of my being. As I observed that young man through the sight of my rifle, I was staring at a point of no return, the very Rubicon of my life, and I crossed it.”
The rising rate of suicides among service members and veterans has led to investigation into moral injury, now thought by many to be one of war’s worst ravages. Dr. Bill Nash, combat psychiatrist during the Battle of Fallujah in 2004, has said that fear did not seem to be a precipitating factor.“Survivor’s guilt, moral injury, feeling betrayed by leaders. . . . That’s what I saw every day.” If this is the case, then it is a radical paradigm shift from prior psychiatric theories. It means that at least in military combat, more psychological harm stems from what service members do to others—or in some cases fail to do for one another—than what is done to them.
Most psychologists and psychiatrists who treat moral injury agree that early identification and treatment of PTSD is important, but there is some concern that the concept of moral injury may not yet be commonly explored in the military. Post-deployment debriefing does not specifically address feelings of guilt or shame, the first warning signs of moral injury, and randomized clinical trials have found little efficacy in psychological debriefing for the prevention of PTSD. Journalist Seth Robson reported, “Soldiers in an all-volunteer force want to be selected for combat missions and they are afraid that psychological testing will prevent them from deploying.”
As one of my military colleagues told me, “Everyone lies on those debriefing forms, everyone.”
Leadership malpractice causes moral injuries and destruction of soldiers’ capacities to trust others. A panel led by former defense secretary James R.Schlesinger investigated the atrocities at Abu Ghraib and made the searing criticism that this resulted from failed leadership “all the way up the ranks.”Although the brutalizing effects of combat are inevitable, minimization of leadership malpractice is a powerful tool in the field of preventive psychiatry. Poor leadership can inflict moral injuries upon our troops that are worse than what the enemy can do to us. Ethical behavior at all levels of the military is very sensitive to policy, practice, and culture.
The military relies heavily on chaplains for ethics training, but this training often references the Bible and religious imagery. Though this has been recognized by some military leaders as problematic, few opportunities are provided for participation by secular ethicists who may be more inclusive in their instruction.
The physiological evidence is clear that sleep deprivation is a recipe for moral injuries. Sleep is the fuel for the frontal lobes of the brain that control social judgment, ethical restraint, and emotional self-restraint. Dr. Shay notes that many of the ugly things that our troops have done to others or even to themselves have occurred during periods of inadequate sleep. Col. Greg Belenky (Ret.), director of the Sleep and Performance Research Center at Washington State University, has suggested that troops wear actographs, small devices worn on the wrist that record weekly sleep hours. He says that “this could be a good way for commanders to know who is fresh enough for duty, who is pulling too many shifts and who is staying up late playing video games. Commanders should manage sleep just as they do fuel.” Adequate sleep can sharpen cognitive and moral skills.
Although scientific discourse about moral injuries as a subset of PTSD is nascent, certain medications and psychotherapies have been shown to be effective. Unfortunately, few military psychologists and psychiatrists who can competently diagnose and administer treatment are on the front lines. Often chaplains become proxies for mental health professionals. Veterans sometimes wait months to see a psychiatrist. Theologians cannot provide adequate mental healthcare for those who need it most. Often, a commander refers troubled soldiers to a chaplain, but chaplains do not necessarily have any professional counseling credentials and have shown very little interest in reaching out to support the nonreligious. We must also recognize that religious evangelizing and proselytizing are not mental health therapies. According to recent polls, over one-quarter of military members do not identify with a specific religion. Going to a chaplain and discussing serious moral injuries in the context of supernatural beings could increase feelings of isolation and hopelessness for the atheist or agnostic. The frequent refrain among military chaplains is “chaplain to all, pastor to some,” but for certain groups and individuals, sharing their faith with others is a religious command.
Ironically, even the nonreligious sometimes prefer to see chaplains for mental health issues including moral injuries—at least at first. The reason for this is that unlike professional counselors, psychiatrists, and psychologists, chaplains are not required to keep records that could damage a service member’s career. Jason Torpy, president of the Military Association of Atheists and Freethinkers (MAAF), has made a strong case for the inclusion of secular humanists in the military family of chaplains. Although this proposal is controversial in both the religious and secular communities, humanist chaplains could be an effective rational alternative for those with moral injuries and other questions about mental health. In the absence of humanist chaplains, religious chaplains must be trained to understand and accommodate nontheistic beliefs and practices. Certain standards could be set for counseling competence and training as secular ethicists, and confidentiality could be preserved, as well as it could for chaplains with supernatural beliefs.
Modern warfare produces abundant instances in which there are no good choices. Desensitization, conditioning, and denial training of our troops have produced a powerful fighting force, but this has come at a high cost—moral injuries with profound repercussions. Lt. Col. Dave Grossman, chair of the Department of Military Science at Arkansas State University, points out that if our society is willing to prepare our military members to overcome resistance to killing, then we are obligated to deal with the psychological wreckage caused by moral injuries.
Moral injuries are serious traumas that can lead to PTSD and all of its terrible consequences. Simply referring the traumatized to chaplains in order to“get religion” will not heal a moral injury—neither for secularists nor for those who are devout believers. We must remember that this injury is self-inflicted. Acts done with brutality or acts of omission with brutal consequences often contradict everything we hold to be true and good at the core of our beings. These acts betray gods for the religious, and they betray humanity for the secular. Both groups betray themselves. In John Knowles’s WorldWar I–era novel A Separate Peace (1959), the character Gene Forrester acts in a moment of semi-reality. Vacillating between two worlds, he almost unconsciously shakes the branch from which his friend Finny falls, ultimately leading to his death. In much the same way, war really does cause many of us to cross the Rubicon in a nebulous split second. We’ll not be the same, ever; but then, none of us really remain so. Just as Gene finally came to terms with himself and learned how to live after his moral injury, so can our troops heal. We recognize a real problem with PTSD and suicides. It becomes clearer every day that moral injury is an important contributing factor and must be addressed from both the theistic and nontheistic perspectives.
- Dokoupil, Tony. “A New Theory of PTSD and Veterans: Moral Injury.” The Daily Beast. December 3, 2012.
- Kennedy, Kelly. “Too Little Sleep Could Be More Dangerous than You May Think.” Army Times, May 20, 2009.
- Lange, Jennifer Travis, CAPT, MC, USA, Christopher L. Lange, MC, USA, and Rex B. G. Cabaltica, MD. “Primary Care Treatment of Post-traumatic StressDisorder.” American Family Physician 62, no. 5 (2000): 1035–1040.
- Maguen, Shira, PhD, and Brett Litz, PhD. “Moral Injury in Veterans of War.” PTSD Research Quarterly 23, no. 1 (2012): 1–6.
- Robson, Seth. “Soldiers Fail to Seek PTSD Treatment or Drop Out of Therapy Early, Research Finds.” Stars and Stripes, May 15, 2012.
- Shay, Jonathan, MD. “Moral Injury.” Lecture at Colombia Medical Center. Video produced by Scott Alderman available athttp://www.youtube.com/watch?v=XBkCg6_ISpQ. Accessed December 27, 2012.
- Torpy, Jason. “Humanist Chaplains: A Litmus Test for Equal Protection.” Free Inquiry 31, no. 6 (2011).
- Warner, Christopher H., MD, George N. Appenzeller, MD, Thomas Grieger, MD, Slava Belenkiy, MD, Jill Breitbach, PsyD, Jessica Parker, PsyD, Carolynn M.Warner, MD, and Charles Hoge, MD. “Original Article | Oct 2011 Importance of Anonymity to Encourage Honest Reporting in Mental Health Screening AfterCombat Deployment.” Archives of General Psychiatry 68, no. 10 (October 2011): 1065–1071.