Moral Injury: The New Post-Traumatic Stress?

Photo: Jayel Aheram

In the moment, battle decisions seem very black-and-white. It's kill or be killed, take down the enemy or risk losing men, losing ground, losing strategic advantages. The men and women who serve in our armed forces are trained to follow orders and focus on immediate goals. They make split-second decisions, but those decisions are based on directives from the officers and commanders above them. Choice rarely factors in. They do what they must.
But in the aftermath -- back home and attempting to adjust to civilian life again -- veterans of war often find themselves replaying disturbing scenes in their minds and questioning their own actions. Many have killed teens and children, witnessed brutal rapes, shot people who seemed to be targets but turned out to be bystanders. They've watched their comrades die and felt the guilt of surviving. And looking back, they begin to wonder: Did I have a choice? Could I have done something less damaging? How can I live with myself after taking part in such ruthless activities?

“You know it’s wrong. But … you have no choice,” explained Nick Rudolph, a 22-year-old Marine.

This quagmire of confusion and contradiction has become painfully familiar to returning veterans of the wars in Iraq and Afghanistan. After seeing similar reactions in countless soldiers, experts have begun to identify this state as moral injury: pain and confusion resulting from damage to a person's life beliefs, values, and moral foundation.
This might seem like it could get lumped in with post-traumatic stress (PTS), but the mental health community has determined that while PTS stems from fear, moral injury has to do with an individual's sense of right and wrong. Symptoms are similar and can include depression and anxiety, difficulty paying attention, and loss of trust. But the morally injured feel sadness and regret, too. They are trying to reconcile the ethics they brought with them into battle with the ugly realities of conflict.
Modern wars have no trenches and our enemies don't always look like soldiers. Our warriors are put in situations that test their ethics and values every single day, and they're fighting wars that much of the American public now believes to be pointless. Of course they return from battle confused and damaged.
“Civilians are lucky that we still have a sense of naiveté about what the world is like,” Navy psychologist Amy Amidon told Huffington Post reporter David Wood. “The average American means well, but what they need to know is that these [military] men and women are seeing incredible evil, and coming home with that weighing on them and not knowing how to fit back into society.” []
PTS has gotten some attention from the medical community and the media, moral injury is still in the shadows, wreaking havoc on our veterans but mostly unacknowledged. And it is shockingly widespread: The U.S. Department of Veterans Affairs estimates that while 52,000 have sustained physical injuries in Iraq and Afghanistan, between 275,000 and 500,000 returning soldiers are coping with PTS and/or moral injury.
Which brings up many complex questions: Should we find ways to harden our fighting men and women against moral injury so they won't suffer later on? Or would that be worse for them in the long run? Should we, as a nation, insist on changing how wars are fought? What is the responsibility of the civilian population in helping these fighters heal?
There are no easy answers. But there are a few things we can do that will help until bigger, better solutions are uncovered: We can listen to combat vets who want to talk about their experiences. We can be patient with them if they are withdrawn, angry, or overwhelmed. We can research support networks and connect veterans coping with moral injury with resources and people who can help them.
And we can acknowledge that black-and-white decisions are a relic of wars past, and that our modern-day warriors are coping with far more complex situations every day of their fighting lives.