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What is Moral Injury? It Can Teach Us About Our Own Humanity

In the World War II miniseries, “The Pacific,” Edward Sledge, a medical doctor in Mobile, Alabama, does everything he can to keep his son Eugene out of the war, including sending him to military school to train as an officer. But Eugene is afraid he will miss the fighting if he has to wait to become an officer, so when he turns 18, he joins his best friend in the Marine Corps. When he tells his father of his decision, Dr. Sledge replies with resignation, “Eugene, the worst thing about treating those combat boys from the Great War wasn’t that they’d had their flesh torn; it was that they’d had their souls torn out. I don’t want to look in your eyes some day and see no spark, no love, no life. That would break my heart.”

Dr. Sledge is describing moral injury, an anguish so deep it leaves only shreds of a soul. Anyone who works with marginalized populations at risk has probably seen that empty stare of a broken spirit: people living in poverty, people struggling with addiction, people carrying unprocessed grief and guilt. Their daily life choices pare away their belief that they are good and worthy of respect. Moral injury afflicts ordinary moral people when they fail their best selves or when no good choice is possible; when they know that whatever they do, they will cause serious harm or violate their core moral values. Their surviving shreds of conscience judge them morally, and they become divided against themselves.

Religious traditions understand this inner anguish, this sense that we have failed our core moral self. In Buddhism, it is called duhkha (bad + empty socket), which in English is translated as suffering; it literally means things out of joint, as when a wheel slips its axle, a shoulder is dislocated and immobilizes us with pain, or when our relationship with our world is off-kilter. In traditional Christian terms, we might call moral injury mortal sin—an affliction of conscience that endangers our very soul.

Shedding human blood is among the three mortal sins, along with apostasy and adultery. Everything else is venial sin, the kind every moral human being experiences when we have failed our conscience, feel terrible, and seek to right the wrong we committed. A confession of venial sins requires things such as being repentant, making amends, and asking for forgiveness—which these days is often reduced in church to a transactional and perfunctory recitation of sins and pronouncement of forgiveness. These ordinary processes, whether profound or perfunctory, require communities and systems of shared moral values and recognizable standards of behavior that support the resolution of harm. Without these, a person afflicted by their sins would be isolated, lost and unmoored from familiar codes of meaning.

Integrating our failures or sins can take a long time, as we learn things about our relationships, our larger world, and ourselves. This process inevitably changes us, and we may have to rethink some of our attitudes or inherited values and ideas. But if the process works, we are able to put past failure in perspective, be informed by it, and gain insight and wisdom into our relationships and ourselves.

Moral injury occurs when this process breaks down because people cannot forgive themselves for something they did, failed to do, or witnessed that threatens or wrecks their moral meaning system.

They lose their ability to trust themselves, others, and their world (Litz, 2009). It can also involve feeling betrayed by someone in authority who should have done their best to be an example of rectitude but who violates what is right when the stakes are extremely high (Shay, 2014).

Military combat veterans have been the first group in which moral injury has been explored, and to understand moral injury in war we need to know something about how military training teaches a new system of what is right (Litz, 2016). Successful combat requires inflicting violence at greater levels than one’s enemies and exhibiting aggression in the face of danger as a quality of character (Powers, 2017). Such a profound internal change in values cannot simply be set aside like an old uniform after military service is over. Veterans can be so changed that they cannot relate to the people they were before or to the families and friends who love them. They can be angry with God, believe that God hates them, or conclude that God does not exist.

For those who return, war can be so devastating that it dominates every waking and sleeping moment for months or years with the torment of remembering and not wanting to remember. For many veterans, the shift back to civilian society and values is impossible because their moral conscience traps them in solitary grief, mistrust, and self-punishing agony. They can feel so hollowed out, numb, and despairing that they cannot find their way back to ordinary relationships, so they live painfully out of joint with ordinary life.

Janci Bridges, who was raised in a missionary family, grew up partly in Russia, and was an independent and adventurous young woman, enlisted in the U.S. Air Force. She was deployed in 2006 to Qatar for six months and was assigned to a mortuary unit. As she notes, she was trained to process bodies but not prepared to handle the potential disgust, horror, and grief of her job. In addition to the demands of dealing with human carnage, a Pakistani contractor attempted to rape her. Though she fought him off, she struggled later with post-traumatic stress.

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Military sexual trauma (MST) occurs three times more often to women but over half the survivors are men. When rape happens, it is one of the deepest betrayals of authority and unit cohesion that ever happens in military life. Even though they are not morally responsible for being assaulted, many survivors feel as if something deeply valuable—their trust in anyone to help them, their gender identity, or the goodness of their flesh—was destroyed, and they may be angry at military authorities or seek a way to regain control over their lives by burying their pain.

What haunts Janci the most since she returned, however, are the dead. She processed twenty-two Air Force remains, but one body in particular is the source of her nightmares—it was in a group of three she received that had spent time in the back of a truck in heat over 100 degrees:

“They had been way out of range, so it had taken them a couple days to make their way to me. The first one came in and it was...pieces. There wasn’t really any form in the body bag. So I did my job, cleaned it up, loaded it back up on the van and the next one came in. And it was the remains of body that had been stuffed into a paper box—just a cardboard box—because there was not enough to put in a body bag.

“[The third body] was a perfect form, a perfect outline of the person. You could see where his feet were standing up, where his hands were laid. The bag had kind of conformed over his face, so you could see his nose and the impression of his chin. That’s the one that haunts me. When I have nightmares, that’s the one I see.”

Once she was stateside, she struggled to reconnect to her family, but she failed and found herself a divorced, single mother.

“When we come home, we’re required to just jump right back into being mom, being in the office, taking care of the household. Moms and wives…are expected to uphold these standards. When you’re not in a good place physically and emotionally, you’re not gonna be able to do everything that is expected…Society-wise, it’s not OK for [women] to have a mental breakdown. It’s not OK for my kids to not have clean clothes because I can’t gather the emotional strength to wash clothes, because even that is an overwhelming and daunting task.

“I went into such a dark depression where I couldn’t handle it. I couldn’t connect with my children. I couldn’t spend time with them. I couldn’t tend to them in the way they needed…. Female veterans, we face different problems, but that doesn’t mean that our problems are any less.” (Stone, 2015)

In the spring of 2015, Janci gave testimony at a conference at the Soul Repair Center in Fort Worth, Texas, about her struggle to come home. After two years of drinking and struggling with everything she carried, she called a friend and asked him to pick up her children after school and take care of them. When he tried to talk her out of killing herself, she hung up on him, locked all her doors and windows, took a bottle of pills, and drank an entire bottle of wine. He jumped in his truck and sped to her house, kicked down the front door, and made her keep walking all night so she wouldn’t die.

Every war is laced with moral injury, but our society’s response has been wholly inadequate to what we ask of those we send on our behalf. We thank the troops for their service and project onto veterans what we judge them to be—romantic heroes to admire, wounded warriors and head-cases in need of help, or naïve victims of war’s evils. With perfunctory comments, formulaic, simplistic pieties, and cookie-cutter greetings, we impose our own assumptions about what we think they need so we can maintain our consciences and move on with what we are already busy doing, assuming they will do the same. But our greeting may have unsettled or offended them. While they are all ordinary people who were trained to face extreme violence under life or death situations, formulaic greetings set them apart. We isolate and dehumanize them as a stereotyped class through admiration or pity, and isolation and alienation are the worst parts of trying to come home with moral injury.

Many religions regard the soul as the core of what makes us human beings, and moral injury is a clue to moral conscience as that core. The awareness that we have failed our core system of meaning is the power of moral conscience when it cannot be reconciled with what threatens it. A shredded moral conscience will risk destroying the whole organism unless it can be restored through right relationships with the whole person and their world. It makes living painfully out of joint and isolated without life-giving relationships with self or others.

A major step in coming home is to come home to flesh, to attend to how it feels to be in our bodies and grounded in knowledge of them. Mindfulness, yoga, contemplative prayer, walking meditation, massage—there are many paths to body-awareness, ways to take the time to be still, to breathe deeply, to quiet a stressed and frantic mind so that restful sleep can return. There is no substitute for reintegrating soul and body as sleep and inner-state awareness. And, as is true with massage, there is no contemplative practice that can be done well alone. Ritual communities are essential to learning spiritual practices and maintaining them with other body-selves, which are necessary to release the hormones for well-being.

Those who survive war and come home are part of us, not a special needs group. As our children, parents, siblings, and friends, they became moral people through the love and guidance of their families and communities. While military moral injury has its own unique cultural and situational character, moral injury is part of the human condition, and veteran trauma is as much ours as civilian trauma. Moral injury can be experienced in prisons, in violent families, in violent crimes, in refugee communities, or in natural disasters. And what helps support recovery for combat veterans is also what helps those who live among us who have never served in the military or gone to war.

No human being can find his or her way to a new moral identity alone. We need trustworthy people who care enough to listen deeply to things we may lack words to describe or fear to describe. We do not need reassuring words and formulas for recovering, which can come from the listener’s anxiety and need to lessen pain. People do not share their deepest pain and humiliations without being able to trust the listener to receive the full truth of their moral injury without judgment or opinions; we need the empathetic, open-hearted attention of listening friends, friends who take the time to hear us so we can tell the story of the destruction of our moral universe. In repeated and varied tellings, the story evolves, and we begin the reconstruction of a moral system adequate to our experiences of moral failure.

Opening our hearts and listening to experiences of moral injury is profoundly transforming and heartening.

We become sharers of a spirit that seeks the restoration of empathy, trust, and friendships that are adequate to honestly facing of the worst things human beings experience. As stories of moral injury take on multiple perspectives and continue to change as they are told, a larger meaning system forms that is resilient enough to hold the memory of trauma as wisdom for living forward, and a community gains strength to integrate trauma instead of letting it control life.

When Eugene Sledge came home from war, he tried to re-enter his life. In a scene from the TV series, we see him interviewed for entrance to college by a well-meaning, perky young woman. He is asked what he could do that will help him in school. In several rounds of trying to answer that same question, he can only talk about his knowledge of weapons. His final answer before walking away is, “I know how to kill Japs; that is what I am good at!” Then we see his father sitting at night in a chair in front of the closed door of Eugene’s room; his head is bent down and his hands cover his face as he listens to the sounds of his son’s nightmares.

In the final scene, we see Eugene sitting against the trunk of a large tree on the lawn of his family home, gazing blankly through the leaves at the sky. His anxious mother comes out and tells him he needs to get busy, to find a job or something to do. His father comes from the house and pulls her away saying, “Leave him be. He needs time. You don’t know what he has been through.”

The true story of Eugene Sledge is that he became a successful and beloved professor of biology, a husband and father. After all he had been through, he found meaning in the beauty of nature and its mysteries. And he found a way to live a life that was more than his story of moral injury so he could share it with the world.

Janci Bridges lived, remarried, had more children, divorced and remarried again. Through these struggles, her growing sense of confidence in herself, and her desire to serve others who struggle to come home, she became a member of the Military Veteran Peer Network in Midland, Texas, and then Peer Service Coordinator of the Network. She tells her own story as a military veteran to break the shame and stigma of the struggle to come home. She wants other veterans to know there are people they can trust who will not judge them, but support their long journey home.

Through the willingness of veterans to speak of the horrors of combat, the moral anguish of war, and the searing losses of their deepest friends, they show us all how any trauma survivor is in danger without adequate time, the love of friends, and social support. Survivors may self-destruct slowly through addictions, failed relationships, despair, and homelessness; others may die by their own hands or strike out in rage.

While not everyone is religious, congregations and local communities are crucial to the recovery process for moral injury. Why? First, moral injury is not a particular disorder limited to veterans, but an anguishing experience of moral failure that can happen to any human being with a conscience and capacity for empathy. Second, moral injury is not a psychiatric “disorder” with a clear diagnosis or symptom profile. It’s a dimension of human suffering familiar to all religious and human traditions that recognize morality has to do with relationships; therefore, moral injury recovery happens via relationships. And third, the anguish of moral injury is, paradoxically, the revelation of a core humanity and a remainder of moral conscience that must be exhumed from the isolating emotions that go hand-in-hand with moral injury: grief, outrage, distrust, shame, remorse, guilt, and despair. Our suffering is testimony to the remainder of morality within us and our soul's desire for new meaning and reconnection. The exhumation process is the beginning of healing and restoring people to their world.

To share the burden of moral injury, to be told another’s story of pain and struggle, is a great gift of a person’s trust and spirit, a gift to be respected and honored with our own honest vulnerability and open spirit with them and each other. If we face our own relationship to moral injury with humility and honesty, we will be better people and better able to understand what living in peace requires of us.

References:

  • Litz, B.T., Stein, N., Delaney E., Lebowitz, L, Nash, W. P., Silva, C., and Maguen, S. (2009). Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy. Clinical Psychology Review, 29, 695-706.
  • Litz, B. T., Lebowitz, L, Gray, M. J., and Nash, W. P. (2016). Adaptive Disclosure: A New Treatment Protocol for Military Trauma, Loss and Moral Injury. New York. Guilford.
  • Powers, B. (2017). Moral injury and original sin: The applicability of Augustinian moral psychology in light of combat trauma. Theology Today. 73(4). 325–337. Available at: http://journals.sagepub.com/doi/pdf/10.1177/0040573616674852. Accessed January 25, 2017.
  • Shay, J. (2014). Moral Injury. Psychoanalytic Psychology. American Psychological Association Vol. 31, No. 2, 182–191.
  • Sledge, E. B. (2007). With the Old Breed: At Peleliu and Okinawa. San Francisco. Presidio Press.
  • Verkamp, G. (2005). Moral Treatment of Returning Warriors in Early Medieval and Modern Times. Scranton. Univ. of Scranton.

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Dr. Rita Nakashima Brock is Senior Vice President, Moral Injury Programs, for Volunteers of America.