Article archive / November 2017
Originally published: . Volume 8, No. 11. Source pages: 11, 12.
Invisible Wounds of War: Moral Injury in our Nation’s Veterans by John Magee, PhD
“PTSD is the name of a syndrome and its list of symptoms, not the portrait of a human being.” –– Dr. Edward Tick, Warrior’s Return, 2015
A Korean War veteran says killing always changes you. Always.
A Vietnam War veteran’s best friend dies in his arms.
Another is haunted by the eyes of a young Vietnamese woman just before she died.
A veteran waits two years in therapy before sharing the full story of what happened in Vietnam one particular day. “They told us to kill everybody.”
A Navy corpsman (medic) wonders what happened to the young men he loaded onto choppers after they were injured. “You never knew what happened.”
Another veteran loaded “parts” of bodies of soldiers he knew into body bags.
A teenager spends his 18th and 19th years in combat in the Korean War, including Chosin Reservoir. By 21, he’s had multiple surgeries for frostbite and eye injuries. Hospital nurses tell him about yelling out in his nightmares.
Another’s best friend is killed accidentally in front of him by another soldier.
A veteran talks about young children accidentally killed as Vietnamese children searched for food.
A Vietnam War veteran says he had to make decisions at age 18 that determined who might die and live. No 18-year-old should have to do that, he says.
Stories of killing are part of war, what many veterans carry unseen. “War is always a sacrificial altar,” Tick wrote in his 2005 book, War and the Soul. Tick founded Soldier’s Heart in 2006, working with veterans returning from war with “invisible wounds.” In war, Tick writes, everything is reduced to “the killing.” In the Vietnam War, success was measured by how many enemy were killed.
“War invariably breaks our hearts,” Tick wrote.
Trauma and Potentially Traumatic Events (PTEs) are not unique to combat Veterans. Estimates of lifetime prevalence of PTEs (equivalent to Criterion A in DSM) have ranged from 59.2 % to 89.6 % in the general population. A study of adolescents found 68 % reported at least one trauma by age 16. Exposure to “multiple” traumas is considered “common” according to some reviewers of PTSD research, with interpersonal violence and sexual assault some of the most common civilian experiences.
Military experiences in war, however, offer a combination of factors which may result in increased problems and alienation for Veterans returning from war, as described by Tick and others. These factors include:
1. Uniqueness of military environment. 2. Nature of combat training to react quickly and violently to danger. 3. Multiple traumas in combat, occurring so quickly a soldier does not have time to recuperate, meaning “more time and more help for healing,” writes Mastakis in her book, Back from the Front. 4. Longer times in combat. Tours for Vietnam War veterans were typically 13 months (Marine Corps) and 12 months (Army). Individuals in Iraq and Afghanistan wars often served multiple deployments. Many World War II soldiers served until the end of the wars in Europe or Pacific. 5. Combat soldiers are typically young. Dr. Marmar, long-time PTSD researcher, called Vietnam “a war fought by teenagers,” reflecting the average age for the combat soldier was 18 or 19 in Vietnam. 6. Strong bond with those with whom they serve in combat. “We go to war for our country,” according to an old saying, “but we’re willing to die for the person next to us in the foxhole.” 7. Lastly, regardless of training, war is never what is expected.
Some mental health professionals have focused on injuries from trauma which are not believed to be fully represented in a DSM diagnosis of PTSD, or in models of PTSD that are anxiety- or fear-based. “Moral Injury” is a relatively new term to describe some trauma survivors, including war veterans. The National Center for PTSD defines “Moral Injury” as the extreme changes occurring to events that “transgress deeply held moral beliefs and expectations,” such as participating or witnessing atrocities. Killing. Killing of civilians.
Tick states these effects are best understood “as an identity disorder and soul wound,” with soul not defined in religious terms, but rather in terms of an individual’s core identity, relationships, conscience, spirituality, meaning of life.
Jonathan Shay has written about Moral Injury for over 20 years, including his books “Achilles in Vietnam: Combat Trauma and the Undoing of Character” (1994) and “Odysseus in America: Combat Trauma and the Trials of Homecoming” (2002). Shay, a former VA psychiatrist, states Moral Injury is not a diagnosis or mental disorder. Shay sees peers of Veterans as the “key to recovery,” not therapists. Shay sees value in therapies, but dislikes the term PTSD and has criticized treatments which are “cookie-cutter” and one-size- fits-all.
Ironically, some treatments for Moral Injury have etiology from the therapists’ own wartime traumatic experiences, including Viktor Frankl (three years in four different concentration camps) and Daryl Paulson (Marine Corps combat Vietnam War Veteran), or from experiences of mental health professionals who served in actual combat zones, such as Scurfield (Vietnam) and Platoni (Iraq and Afghanistan).
There are common concepts found in literature on moral injury:
1. Damage due to Moral Injury can be profound, including damage to an individual’s “identity” and “soul.” “Spiritual” damages are defined in terms of meaning of life, openness, reverence for life and others, capacity for intimacy, ethical responsibility, and the ability to experience love, joy, gratitude, etc. 2. Moral Injury is not a formal diagnosis. The construct has overlap but is not synonymous with PTSD; PTSD is typically viewed as too narrow a definition for injuries from morally transgressive traumas. 3. In treatment, an individual must directly deal with trauma and the reality that occurred. 4. An individual must tell his/her “story.” This process not only can benefit the survivor, but also other veterans/survivors, family members, and civilians who hear the story. 5. Progress from moral injury is considered a process of “healing.” 6. Treatment is individualized to each person; treatment processes are flexible because everyone is different. Treatments may include numerous components, including individual and group psychotherapy, “reconciliation visits,” rituals, EBTs, mindfulness, arts and creative expressive therapies, etc. 7. Society has played a role in problems which resulted in increased alienation of combat veterans. Society has a role in healing. 8. Relationships are vital in change. The most important decision for many is often choice of therapist, according to Tick and others. Herman reports a therapy “group” can help create “a sense of belonging” that the veteran has lost. Therapy relationships offer “safety” from which Veterans can begin the risks inherent in therapy.
In recent years, Moral Injury has had increasing recognition within mental health as a major factor for individuals exposed to trauma, killing, and atrocities, including military service veterans. The National Center for PTSD recognizes the construct. Some research has focused on effects and treatments for Moral Injury. Psychological instruments, such as the Moral Injury Questionnaire, have been developed. Research, including the National Vietnam Veterans Readjustment Survey, the congressionally mandated survey of Vietnam Veterans in the 1980s, has consistently found large effect sizes of increased severity of PTSD symptoms for those who report killing others in combat, including psychometric testing and reports of problems such as violent outbursts, even when controlling for severity of combat and other factors.
But barriers to treating moral injury in Veterans remain. Major reviews of PTSD research typically have not included mention of Moral Injury specifically, or spiritual issues in general. The majority of treatments for trauma target only PTSD DSM symptoms as measured by traditional PTSD testing, not meaning of life issues, even when “quality of life” is included as an outcome measure. Ironically, Edna Foa (developer of Prolonged Exposure, a manual based Evidenced Based Treatment for PTSD) believes one of three core components to target in PTSD relates to beliefs about meaning of life and self. DSM 5 criteria of PTSD have been criticized for inadequacy by some major researchers, with recommendations the criteria not be used in PTSD research. Lastly, mental health professionals working outside of the Department of Veterans Affairs rarely hear of Moral Injury.
Tick recommended therapists working with combat Veterans “must have deep love, compassion, and comprehension” as they navigate therapy, which he describes as “a shared moral journey.” Tick also recommended therapists working with war veterans must be willing to have more self- disclosure and give more of him/herself to those who served in combat. Tick himself has accompanied many Veterans on “reconciliation trips” back to Vietnam since 2000. Similar trips were profiled in the recent documentary on Vietnam by Ken Burns.
Military members are asked to serve and risk their lives in combat. Large-scale research by the Rand Corporation on the recent wars in Iraq and Afghanistan supported that exposure to combat events in war zones was high, with exposure to different types of combat trauma ranging from 5 to 50 percent. A relatively high number reported seeing the killing of civilians. Events that can lead to Moral Injury are unfortunately found frequently in combat.
An angry combat Veteran once confronted Tick in his office, challenging why Tick worked with combat Veterans. Tick responded: “Because brotherhood is forever. Because I remember and honor you and your story.”
War inevitably breaks hearts, Tick wrote in 2015. Many continue to look for ways for the invisible wounds of veterans to begin healing.
This article is part of a historical newspaper archive. Read the original issue for its original layout, photographs and graphics.