Returning to Life: Understanding How Moral Injury Impacts Veterans
On an azure afternoon in October 2012, I drove across the San Rafael Bridge that straddles the glittering water of the San Francisco Bay. I parked my car beside the looming, pale walls of San Quentin State Prison and walked up the hill to the entrance dressed in a clergy collar and Johnny Cash black.
At the check-in area I met Susan Shannon, a Tibetan Buddhist graduate student I knew at Starr King School for the Ministry in Berkeley. Susan and I were accompanied into the prison by a retired US Marine Corps Colonel and Vietnam War veteran named “Sunny,” and a Dutch psychologist, Jacques Verduin, who founded and directs a nonprofit called Insight Out, which teaches mindfulness and inner transformation in California prisons. Jacques taught trauma recovery in San Quentin for nearly two decades and started a yearlong program for inmates called GRIP (Guiding Rage Into Power), which teaches emotional intelligence, victim impact awareness, and nonviolence practices.
Susan was working with Jacques and knew of my research on moral injury in veterans. She asked me if I wanted to speak to a new group of military veterans about it, and I said, “Yes, absolutely.” After being cleared to enter, we made our way through the complex gauntlet of gates and down a long sidewalk through the grounds to one of the buildings.
One of the graduates of the GRIP program was Ron Self, a Marine Corps combat veteran. Ron thought veterans needed a program of their own, but he could not start a group on his own as an inmate, so Jacques sponsored Ron’s effort to start a group, called Veterans Healing Veterans from the Inside Out (VHV), through his existing teacher status. My visit, the first of three over eight months, was during VHV’s first session.
As Jacques, Susan, Sunny and I walked to the meeting room, I learned that the men in the VHV group were mostly Vietnam-era veterans, with a few from Desert Storm, and only about half had been in combat. They told me Ron was a Marine Corps special ops veteran who served from 1987 to 1996 and had a reputation in prison for being so lethal that no one bothered him.
We found the twenty men in prison blues waiting for us. Ron greeted us as we arrived. He was nearly six-feet tall and powerfully built, with sandy-brown hair, glasses, and a poised, self-possessed intelligence. Ron called the group to order and had everyone sit in a circle of chairs. After some preliminaries, Jacques introduced me, and I explained what I knew about moral injury.
I began by telling them about an article written by a group of VA clinicians in 2009 that distinguished moral injury from post-traumatic stress disorder (PTSD). The clinicians described moral injury as a deeper, longer-lasting form of suffering that the VA has not been treating. Unlike PTSD, moral injury is not based in terror, and what works for PTSD may not work for moral injury, so it remained untreated.
Moral injury is an affliction of moral conscience, a negative judgment we pass on ourselves in response to violating our core moral values or being contaminated by exposure to evil. It can lead us to feel unforgiveable for something we did, failed to do, witnessed, or endured, and it can cause us to conclude we are no longer good and decent persons. Such judgments fuel a host of moral emotions, such as guilt, shame, grief, remorse, disgust, and outrage; and when we lose meaning or faith, we also lose our ability to trust our world, others, and even ourselves. We become divided against ourselves.
Joining the military involves a profound internal change in many core values, changes that are annealed by repeated drills and the pressures of war. I did not need to tell those veterans that military training requires learning to inflict violence more efficiently and better than one’s enemies or that, in the context of the military, exhibiting aggression in the face of danger is a mark of character. Veterans understand that the courage to fight and serve others is based on unit bonding, which makes combatants willing to die to save others. Their bonds of love can be so deep that they constitute the closest relationships in a young enlistee’s life. Losing a friend in battle is like losing a soul mate—the deep love of a lifetime—and the losses of war are riddled with intense grief and, often, with survivor guilt. However, what even military veterans do not consider is that such bonds can render ordinary civilian relationships untrustworthy, transactional, and shallow by comparison.
Military values that veterans have learned cannot simply be set aside like an old uniform after their military service is over, even for those who never serve in combat. People can be so changed by military service that they cannot relate to the people they were before or to the families and friends who love them. The sorrow and pain veterans carry can often erupt as anger, and they end up pushing people away because they no longer trust.
For veterans with moral injury, the shift back to civilian society and values can become impossible because their moral conscience traps them in solitary mistrust and self-punishing agony. They may have lost their best friends in their unit or feel ashamed of things they did or failed to stop. They can feel so hollowed out, numb, and despairing that they cannot find their way back from emotional isolation and end up living painfully dislocated from ordinary life and relationships. They can be angry with their government, military authorities, even God. They may believe that God hates them or conclude that God does not exist. Because moral emotions such as shame, grief, guilt, and outrage are so painful, moral injury can be pushed down and carried for years, even decades, as silent, hidden suffering. Unable to go back to who they were before the military or see a way out of the pain they carry, some veterans give up or lash out in fury.
The men I met that October day listened carefully to me and asked excellent and perceptive questions. Jacques asked them if anything I said related to their life experience. Some of the men spoke of their feelings that the military had turned them into killers, and they were angry about it. One of the men who served in Vietnam said he did not return with “any of that PTSD stuff.” He thought he was fine, but upon reflection he realized he was not. Even though he had always planned on becoming a Christian Pentecostal minister, he returned home from Vietnam an atheist and never went back to church. He never considered his rejection of faith as being related to his war experience.
As the men told harrowing stories of Vietnam, I began to think about what my own father might have experienced as a field station medic. He served two tours while I was finishing high school, and he returned a different person. He was cold, controlling, and distant. We fought a lot, and we remained estranged until he died eight years after his return home. I felt something deep inside me shift as I listened to those men talk about their experiences. The weight of the terrible details about that war began to sink in. I had never connected what happened between my father and me to the war, and as I realized how much he’d changed, I saw the impact of moral injury on my own life.
After the group adjourned for dinner, Ron lingered to talk to Jacques and me.
“This moral injury idea, I’m going to have to think about it some more,” he said. After pausing a moment, he continued: “I was team leader of a special ops unit, and we completed 127 successful missions.”
“I had heard you were special ops,” I affirmed.
He took a deep breath.
“In our 128th mission, I lost my entire unit, including my cousin.”
I took this information in for a moment, and because it was time for him to leave I could only think to say, “I’m sorry that happened to you.”
“Yeah,” he said softly, as something in his eyes changed. “This moral injury idea, it’s important.”
As we walked back to our cars, Jacques thanked me for coming and asked if I noticed something shift in Ron when he spoke to us after the meeting.
“Yes,” I said. “It was subtle, but his leader persona opened a little.”
Jacques had sensed it as well.
When I returned for a second visit to San Quentin in mid-December to see if our discussion of moral injury had been helpful, the group was excited to tell me that it was, in fact, the most helpful concept they had ever encountered in trying to understand their lives. Ron had started taking a prison English course that gave him access to research. He found papers on moral injury, which he read and shared with the group. We went around the circle so each of the men could share an insight that learning about moral injury had given him.
The men had discovered war and prison were very similar. Both, they said: created a total authoritarian environment that controls every aspect of life; involved sanctioned violence in life or death contexts; inflicted a high penalty for trying to leave; and offered no process to help with a transition back to ordinary life.
The biggest surprise came from Sunny, the retired Marine Corps colonel. When his turn came, he said he had not believed in such a thing as moral injury. He thought I was just giving the men excuses and a way to complain. But as he watched what happened every week in the veterans group, he said he changed his mind. He explained the concept of moral injury to a VA medical doctor who works with veterans in prisons, and the doctor told Sunny it “was the most important thing he had learned to help him treat veterans.”
Sunny looked directly at me and said, “I was rude to you, and I apologize.” And as he escorted me out of the prison later he confessed that he had come to think differently about his Vietnam War experience.
“I realized I have been really angry at my government,” he said, “for dishonoring the military by putting us in a war they thought was unwinnable and never giving us enough support to win it.”
For recovery to happen people must speak about their moral injury, but they cannot share their deepest pain and humiliations without being able to trust the listener to receive the full truth of their experience without judgment or opinions. To share inner anguish, we need the empathetic, openhearted attention of listening friends. We need friends who take the time to hear us so we can tell the stories of what destroyed our moral universe and find ways to create a meaningful system that can enable us to integrate our trauma. Veterans Healing Veterans makes recovery from moral injury possible for those in prison because everyone involved shares a common military culture and understands each other’s experiences.
When it was my turn to speak at our second meeting, I thanked the veterans for sharing their stories of moral injury. To be told another’s story of pain and struggle is, I believe, a great gift of a person’s trust and spirit, a gift to be respected and honored with our own honest vulnerability. I explained that they helped me feel compassion for a father I had been estranged from for more than forty years. Every Christmas, I bought poinsettia flowers at my church for people who meant a lot to me, but I had never bought one for my father. For Christmas 2012, thanks to this group of veterans, I bought a poinsettia for my father and, after forty years of a hardened heart, I started to miss him and truly grieve his passing.My third and final visit to the prison was five months later, when the veterans met as a group for the last time. A couple of them were getting paroled, the rest were becoming facilitators for the next VHV cycle.
In a 2016, TedxSanQuentin talk, “How to End Veteran Suicide,” Ron shared the story of his secret, failed suicide attempt, which took place in his prison cell in November 2011. He spoke poignantly of his love for the men he had lost in combat and eloquently of the need for a better process for people leaving the military. His solution is Boot Camp Out, a training for civilian life as ritualized and intense as boot camp in. Ron was released on parole in November 2017, and he still leads VHV but wants to make Boot Camp Out his next big project.
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 how many trauma survivors can experience moral injury. Without the love of friends, social support, and adequate time to overcome the pain of trauma, survivors may self-destruct slowly through addictions, overwork, failed relationships, despair, and homelessness. Some reach the end of their ability to cope and die by their own hands.
While moral injury experiences can never be forgotten, recovery happens via trustworthy relationships. As sharing unfolds over time with friends, the pain of moral injury can cease to dominate and destroy a life. Many veterans also seek to be of service to others and to make a difference for good, which enables them to experience a sense of worth and value. As moral injury is placed in perspective with the building of a new life, those who recover can begin to feel compassion for themselves and for others.
Moral injury is not a disorder with a clear diagnosis or symptom profile. It is a normal response to moral failure that can happen to any human being with a conscience and capacity for love and empathy.
It’s a dimension of human suffering familiar to all religious and humanist traditions.
Our suffering is testimony to the soul's non-negotiable requirements for meaning and connection. The anguish of moral injury reveals, paradoxically, what it hides: the indestructibility of conscience and our profound need for love. These elements of our humanity can be exhumed from beneath the outrage, distrust, shame, remorse, guilt, and despair that accompany our moral failures. The exhumation process is the beginning of our healing and restoring us to our world. I think of it as resurrection and the start of a hard-earned wisdom that is a gift to us all.
When I first encountered the concept of moral injury in late 2009, I could not have anticipated how much it would change my own life as the daughter of a combat veteran. While I have had a successful career as a feminist theologian and professor, moral injury has closed a circle in my life that needed closing. It has healed a very old wound and changed me more than any other work of my life, and it has brought me back to some the spiritual practices of the Buddhism that formed me for the first six years of my life in Japan.
I had thought I would retire someday as a senior professor, but instead I find myself living into a new chapter outside the world of academe, returning to old aspects of my life long buried. With my new position at Volunteers of America, I have an opportunity to join, through hands-on work, the intellectual capital I have accumulated with the deepest impulses of my heart to heal the brokenhearted from wounds I know myself. It’s work I never imagined doing and work that feels exactly right.
Rita Nakashima Brock is senior vice president, moral injury, for Volunteers of America.