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The Moral Injury of War: Using 'Soul Repair' to Prevent Veteran Suicides

The Moral Injury of War: Using ‘Soul Repair’ to Prevent Veteran Suicides

The difficult process of repairing a soldier’s moral conscience begins with a societal approach to compassionate care—a commitment to addressing war veterans’ moral anguish as well as PTSD.

March 2013

By Rita Nakashima Brock and Gabriella Lettini

In “Soul Repair,” Rita Nakashima Brock and Gabriella Lettini tell the stories of four veterans of wars from Vietnam to our current conflicts in Iraq and Afghanistan—Camillo “Mac” Bica, Herman Keizer Jr., Pamela Lightsey, and Camilo Mejía—who reveal their experiences of moral injury from war and how they have learned to live with it. Brock and Lettini also explore combat effect on families and communities, and the community processes that have gradually helped soldiers with their moral injuries.

Soul Repair (Beacon Press, 2012) aims to help veterans, their families, members of their communities, and clergy understand the impact of war on the consciences of healthy people, support the recovery of moral conscience in society, and restore veterans to civilian life. When a society sends people off to war, it must accept responsibility for returning them home to peace. The following excerpt of the book’s introduction describes moral injury as a growing problem that’s sadly not being sufficiently addressed by today’s society.

After we send men and women off to war, how do we bring them home to peace?

Obviously distraught, the three people huddled, whispering to each other while they waited patiently at the end of a long line that had formed after Rita’s lecture on moral injury in Houston, Texas. When the two women and the man finally reached her, they said they were from a United Methodist Church. Their words tumbled out on top of each other:

“You don’t know how much your lecture meant to us . . . We didn’t know how to help him . . . The suicide was such a shock . . . The whole church is heartbroken . . . We wish we had known about moral injury . . . It makes so much sense . . . Maybe we could have helped him.”

The group’s distress was raw and urgent. Their description was disjointed, as if their jumbled memories had not come into focus. When they realized that Rita was puzzled, they filled in some of the details. They explained that the suicide of a young veteran, deeply beloved in their church, was unexpected. The whole church community was reeling and struggling to understand how it had failed him. He was a hero to so many, they said, that the Department of Veterans Affairs (VA) had sent crisis counselors to a national gathering of veterans meeting at the time of the suicide. After the group explained the impact of the suicide on them and their community, one of the women said, “We want to learn more about moral injury. Our community needs this information. We couldn’t save Clay, but maybe we can help save others.”

Within days of Rita’s lecture in April 2011, national media sources reported Clay Warren Hunt’s story. He was a twenty-eight-year-old former marine corporal who earned a Purple Heart serving in Iraq and Afghanistan. He had been active in a suicide-prevention program for vets. Since 2009, he had been a model to other veterans of a successful return home. He married and started college in California; he advocated for veterans’ rights and worked in disaster relief. He was being treated for post-traumatic stress disorder (PTSD). Then, his marriage ended, he left school, went into treatment for depression, and returned to Houston where he got a job and an apartment in Sugar Land, Texas. On March 31, 2011, he bolted himself in that apartment and shot himself. Over a thousand people attended his funeral.

Veteran suicides average one every eighty minutes, an unprecedented eighteen a day or six thousand a year. They are 20 percent of all U.S. suicides, though veterans of all wars are only about 7 percent of the U.S. population. Between 2005 and 2007, the national suicide rate among veterans under age thirty rose 26 percent. In Texas—home of the largest military base in the world and the third-highest veteran population—rates rose 40 percent between 2006 and 2009. These rates continue, despite required mental health screenings of those leaving the military, more research on PTSD, and better methods for treating it. Veterans are also disproportionately homeless, unemployed, poor, divorced, and imprisoned. The statistics, however, do not disclose the devastating impact of war on veterans’ families and friends, on their communities, and on other veterans.

The journey home to peace is perilous after war. We can make it less lonely and lethal. The veterans’ stories that unfold in this book describe a wound of war called “moral injury,” the violation of core moral beliefs. The stories reveal the lifelong struggle of veterans to live with its scars, the impact on their families, and the various ways our society can support the recovery of those who experience moral injury.

Moral injury is not PTSD. Many books on veteran healing confuse and conflate them into one thing. It is possible, though, to have moral injury without PTSD. The difference between them is partly physical. PTSD occurs in response to prolonged, extreme trauma and is a fear-victim reaction to danger. It produces hormones that affect the brain’s amygdala and hippocampus, which control responses to fear, as well as regulate emotions and connect fear to memory. A sufferer often has difficulty forming a coherent memory of a traumatic event or may even be unable to recall it. Symptoms include flashbacks, nightmares, hypervigilance, and dissociation.

Our ability to calm or extinguish fear and process emotions is often impaired by trauma, and a previous history of emotional trauma or a brain injury can make a person more susceptible to PTSD. Dissociative episodes can put sufferers back into experiences of terror and make them lose a sense of the present. They can feel unreasonable fear in ordinary situations or startle at sounds that mimic battle. They may experience a compulsive need to retell stories of terror, to reenact them, and to transfer past fear-inducing conditions to the present. With PTSD, memory erupts uncontrollably and retraumatizes the sufferer, which can make retrieving a coherent memory nearly impossible. Clinicians have treatments for PTSD, and such therapies are crucial for those diagnosed with it.

The moral questions emerge after the traumatizing symptoms of PTSD are relieved enough for a person to construct a coherent memory of his or her experience. We organize emotionally intense memories into a story in the brain’s prefrontal cortex, where self-control, planning, reasoning, and decision making occur. The mind creates a pattern from memory fragments stored in various places. Emotions are essential to moral conscience, but until people can construct enough of a coherent narrative to grasp what they did, they cannot evaluate it. The brain organizes experiences and evaluates them, based on people’s capacity to think about moral values and feel empathy at the same time.

Marine veteran and philosopher Camillo “Mac” Bica used the term moral injury in his war journals from Vietnam, and, from the perspective both of warrior and of moral philosopher, he has explored the agony of this inner judgment against himself. Moral injury is the result of reflection on memories of war or other extreme traumatic conditions. It comes from having transgressed one’s basic moral identity and violated core moral beliefs.

Moral injury names a deep and old dilemma of war. The moral anguish of warriors defines much literature about war from ancient times to the present, such as the Greek Iliad and Indian Bhagavad-Gita, both war epics; the Hebrew Psalms; and modern novels and films, such as Catch-22, The Deer Hunter, or Matterhorn. We see discussions of moral injury in current memoirs of the wars in Afghanistan and Iraq. In Packing Inferno: The Unmaking of a Marine, Tyler E. Boudreau, a veteran of Iraq and former Marine officer, reflects on the apparent inability of societies to learn from works of art and history about the torture that war inflicts on the souls of veterans. He concludes that societies have understood war only as much as they really wanted to learn about it and its deeper meaning.

Not everyone was so unable or unwilling to understand, Tyler notes. In Mrs. Dalloway, Virginia Woolf portrayed the suicidal anguish after World War I of Septimus Smith as if she were a veteran herself. Tyler reflects on her perceptive depiction:

She was just a writer. That tells me, if nothing else, that the information was there. The capacity to know existed. It wasn’t beyond human understanding. They weren’t too primitive. If Virginia Woolf knew about combat stress, everybody else could have known, too. They did not know because they didn’t want to know.

Still, not even Tyler could face telling the truth about war. After he left the Corps, he worked as a Casualty Assistance Calls Officer (CACO), which required him to call the parents of wounded Marines. He could not bring himself to call soldiers’ families and report honestly that, among the wounds they suffered, “your boy is coming home with a broken heart.” Never once was he able to say it, and he regrets it still that he did not.

Moral injury results when soldiers violate their core moral beliefs, and in evaluating their behavior negatively, they feel they no longer live in a reliable, meaningful world and can no longer be regarded as decent human beings. They may feel this even if what they did was warranted and unavoidable. Killing, torturing prisoners, abusing dead bodies, or failing to prevent such acts can elicit moral injury. Handling human remains can be especially difficult; for example, in 2004, Jess Goodell served in the Marine Corps’ first Mortuary Affairs unit in Iraq, which required her to recover and process remains of fallen soldiers, including drawing their outlines where they had fallen, filling in missing parts in black.

In her memoir, Shade It Black: Death and After in Iraq, she describes the devastating aftermath of this work of facing death every day. Seeing someone else violate core moral values or feeling betrayed by persons in authority can also lead to a loss of meaning and faith. It can even emerge from witnessing a friend get killed and feeling survivor guilt. In experiencing a moral conflict, soldiers may judge themselves as worthless; they may decide no one can be trusted and isolate themselves from others; and they may abandon the values and beliefs that gave their lives meaning and guided their moral choices. Recently, Veterans Affairs clinicians have begun to conceptualize moral injury as separate from PTSD and as a hidden wound of war.

The consequences of violating one’s conscience, even if the act was unavoidable or seemed right at the time, can be devastating. Responses include overwhelming depression, guilt, and self-medication through alcohol or drugs. Moral injury can lead veterans to feelings of worthlessness, remorse, and despair; they may feel as if they lost their souls in combat and are no longer who they were. Connecting emotionally to others becomes impossible for those trapped inside the walls of such feelings. When the consequences become overwhelming, the only relief may seem to be to leave this life behind.

The tired truism, “war is hell,” is also true of its aftermath, but the aftermath can be endless. War has a goal and tours of duty that end; its torments are intense and devastating, but they are not perpetual. War offers moral shields of honor and courage. Its camaraderie bonds warriors together around a common purpose and extreme danger. War offers service to a larger cause; it stumbles on despair. On the other hand, moral injury feeds on despair. When the narcotic emotional intensity and tight camaraderie of war are gone, withdrawal can be intense. As memory and reflection deepen, negative self-judgments can torment a soul for a lifetime. Moral injury destroys meaning and forsakes noble cause. It sinks warriors into states of silent, solitary suffering, where bonds of intimacy and care seem impossible. Its torments to the soul can make death a mercy.

The suffering of moral injury is grounded in the basic humanity of warriors. That humanity lies deeper in them than its betrayal in war. They learned their ethical values first from their families, neighbors, schools, and religious and community organizations. Whether people are religious, spiritual, or secular, most of us are trained to respect others, to relate to a world bigger than ourselves, and to feel compassion for those who suffer. For many families, a military career is one way to embody core moral values like love of country and service to others.

When veterans return to our communities after war, we owe it to them and to ourselves to do our best to support their recovery. To do so, however, we must be willing to engage the same intense moral questions that veterans undertake about our own responsibility as a society for having sent them to war. This book is an invitation to accept that transformative process.

The military, which trains people to kill, also teaches moral values to all who serve. Soldiers are instructed in the principles of just war and the legal and ethical conduct of war, including the need to protect noncombatants and to refrain from torturing prisoners. People in the military often understand the principles of just war and international standards better than members of the religious and philosophical traditions that espouse them. Paradoxically, current military regulations require soldiers to fight all wars, regardless of their moral evaluations, which can create profound inner conflicts for them.

Combatants who support a war and serve willingly also experience moral injury because the actual conditions of war are morally anguishing. As every veteran of combat knows, the ideal of war service, the glamour of its heroics, and the training for killing fail to prepare warriors for its true horrors and moral atrocities. The wars in Iraq and Afghanistan, especially, present terrible moral dilemmas for engagement because the lines between civilians and combatants are invisible and because the absence of clear battle lines makes every situation potentially lethal. Even women, children, and family pets can be dangerous or used as shields. These category confusions are also moral confusions, and they are aggravated by the reflexive shooting methods the military started teaching after World War II: the training suppresses combatants’ ability to exercise moral discernment before taking action. Many veterans recount with anguish stories about shooting reflexively at unarmed civilians in a split second, without making a conscious decision to take a life. In addition, many soldiers experience repeated exposure to these morally compromising situations through multiple deployments.

War’s lingering phantoms haunt every society. In the bodies and souls of those who experience combat, war always comes home to the rest of us. Veterans’ families and communities, especially, carry these burdens. While the suicide rate is especially high among the veterans of the current wars, suicide still bedevils the eighteen million combat veterans in the United States. For the country has sent its forces into war nearly every year since 1945. During the years of the war in Vietnam, conscription and public resistance to the conflict traumatized the entire generation that reached adulthood between 1964 and 1975. In many traditional societies, all returning soldiers were required to undergo a period of ritual purification and rehabilitation before reentering their ordinary lives after war. For example, the Navajo people of the Southwest developed a ceremonial process called ’Anaa ’jí, or “the Enemy Way,” which was used to cure sickness that came from contact with a deceased non-Navajo, participation in war, fatal accidents, and other encounters with death, such as corpses and graves.

Some forms of it took almost two weeks to complete. Its adaptation to modern times is used to reintegrate veterans of combat serving in the U.S. armed services and is supported by VA health professionals. In another example, Christian churches in the first millennium required anyone who “shed human blood” to undergo a rehabilitation process that included reverting to the status of someone who had not yet been baptized and was undergoing training in Christian faith. Now long in disuse, this ancient form of quarantine was required because early Christians understood that killing or participating in war, regardless of the reasons, injured the souls of those who fought. Returning soldiers were commonly expected to spend at least a year among the order of penitents.

Whether we support or oppose a particular war, we contribute to a better, more moral society when we take responsibility for healing the devastating aftermath of combat. To accept responsibility requires people courageous enough to face the moral questions that war raises and people willing to listen compassionately and carefully to the moral anguish of veterans.

As the authors of this book, one an immigrant from Italy and the other an immigrant from Japan, we have been deeply affected by moral injury through combat veterans in our families. While neither of us is a veteran, we, like many millions of people, were born and raised under the shadow of war. As we relate below, we have also been deeply affected by our work with veterans today.

Reprinted with permission from Soul Repair by Rita Nakashima Brock and Gabriella Lettini and published by Beacon Press, 2012.

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