Moral injury is a relatively new and puzzling category to the Department of Veterans Affairs, National Center for PTSD. Lots of researchers seem to recognize that it exists, but nobody can categorize it (Maugen and Litz). Or figure out an effective therapy for it, one that is evidence based, as they say, such as cognitive behavioral therapy (CBT), or prolonged exposure therapy (PE). The practical irrelevance of these therapies when dealing with moral injury makes moral injury a challenging category. 

Events are considered morally injurious if they “transgress deeply held moral beliefs and expectations,” as one of the first academic papers sponsored by the VA put it (Litz, et al., pp. 696, 700). A moral injury occurs when an act shatters the moral and ethical expectations of soldiers and others, including expectations about fairness, the value of life, and that leaders will tell the truth.

Though the publications of the VA recognize the existence of moral injury, it is not a currently accepted diagnostic category. One can receive recompense and treatment for PTSD, but not for moral injury, except on an experimental basis. Shame, guilt, and anger at the self or others’ betrayal of basic human values are central to moral injury. These emotions may occur with PTSD, but they are not key to its definition. PTSD is generally regarded as a fear-based disorder (in spite of DSM-5’s currently grouping it with dissociative disorders). Moral injury is guilt and shame based (Maguen and Litz, p. 2).

As I explain below, I think the VA has depoliticized what was originally a political concept.

Themis

The term was introduced by Jonathan Shay, in a book that compared the Vietnam War with the Trojan War, as portrayed in The Iliad. In Achilles in Vietnam: Combat Trauma and the Undoing of Character (1994), Shay attributes moral injury to the violation of themis, a term he borrows from the ancient Greeks.

Themis means what’s right, proper, and customary. It is the mark of civilized existence. As Shay, a VA psychiatrist for many years puts it, “veterans can usually recover from horror, fear, and grief once they return to civilian life, so long as ‘what’s right’ has not also been violated.” (p. 20) This makes moral injury an issue of knowledge, not just an emotional experience for which the psyche was unprepared.

In Vietnam, the most serious violations of what’s right took place at the command level. As an example, Shay quotes a service member whose platoon was ordered to attack a group of fishing boats at night, under the belief that they were Vietcong unloading weapons.

Daylight came [long pause], and we found out we killed a lot of fishermen and kids. What got us thoroughly fucking confused is   . . . the fucking colonel says, “Don’t worry about it. We’ll take care of it.” Y’know, uh, “We got body count!” “We have body count!” So it starts working on your head. So you know in your heart it’s wrong, but at the time, here’s your superiors telling you that it was okay . . . . They wanted to give us a fucking Unit Citation— them fucking maggots. A lot of medals came down from it. The lieutenants got medals, and I know the colonel got his fucking medal. And they would have award ceremonies, y’know, I’d be standing like a fucking jerk and they’d be handing out fucking medals for killing civilians. (pp. 3-4)

The result is not only moral confusion, but disorientation, as soldiers were told, in effect, “you didn’t experience it, it never happened, you don’t know what you know.” (Shay, p. 171)

For Shay, moral injury stems from the failure of command to set proper limits and goals. In addition, command did not allow for the proper grieving of fallen comrades, whose bodies were whisked away by a helicopter almost as soon as a battle was over. Within a day, the soldier would be replaced by another, almost as though it never happened. The comparison between the extended weeping and grieving at the funeral pyres of the dead Greeks at Troy and the lack of an opportunity for ritualized grieving in Vietnam is the central contrast Shay draws between the ancient and modern war. (Shay basically ignores the fact that the Iliad’s account of the Trojan War is a myth, but since myths reflect values, perhaps it doesn’t matter very much.)

Depoliticizing moral injury

Though failure of command to adhere to moral values is still an item in the experimental “moral events scale,” used to diagnosis moral injury, the emphasis seems to be changing (Nash et al.). Today moral injury is most often used to refer to the feelings of guilt, shame, and remorse felt by service members who killed in combat, often a non-combatant, or failed to save the life of a comrade. Soul Repair: Recovery from Moral Injury after War, a popular book on the subject, is deeply sympathetic to soldiers who were often placed in morally untenable positions. At the same time, its topic is helping soldiers who have been morally harmed by killing, whether the victims were enemy soldiers or civilians. Many also feel deep guilt at not being able to save the life of a buddy. Many feel guilt at simply surviving.

This pattern is also apparent in the VA funded research on the topic (Nash et al.). Failure of command to uphold moral standards is still an element of moral injury, but the emphasis is increasingly on the shame and guilt of the individual soldier. The approach is sympathetic, but the concept of moral injury has lost its critical edge, much as PTSD lost its critical edge in the years after the Vietnam War.

At first, PTSD was seen as the result of putting soldiers in the impossible situation of fighting an unwinnable and pointless war, one in which it was sometimes impossible to distinguish combatants from civilians. PTSD began as political criticism of the Vietnam War. Or as Judith Herman puts it, “every instance of severe traumatic psychological injury is a standing challenge to the rightness of the social order.” (p. 51)

One may say the same thing about moral injury. It comes not simply from killing in war, or seeing buddies killed and being unable to save them. Moral injury comes from being ordered to kill for unclear purposes, in a pointless war, that goes on and on, in circumstances that make it almost impossible to distinguish combatants from civilians. Moral injury is compounded when command is casual about killing, and fails to ritualize grieving in a serious fashion. An account of both is found in the fiction of Phil Klay, an Iraqi veteran, particularly “Prayer in the Furnace,” an account of a warrior’s grief turned to madness, akin to the wrath of Achilles.

Shay’s definition of moral injury focuses on the betrayal of “what’s right” in a morally significant situation by someone who holds power (pp. 3-22). Turning moral injury from a political into a strictly psychological category reminds us that the medicalization of morality almost always locates the problem within the troubled individual.

There is more than enough blame to go around, the reader might reply, and soldiers who kill non-combatants, mistakenly or not, should feel shame and grief. Indeed. But those who put them in that situation should feel more, and the psychologization of moral injury should not let leaders off the hook, including presidents and politicians. That, though, seems to be the future, at least judging by the current research.

The next post addresses the occurrence of moral injury in civilian life. 

References

Rita Nakashima Brock and Gabriella Lettini, Soul Repair: Recovering From Moral Injury after War. Boston: Beacon Press, 2012.

Judith Herman, Trauma and Recovery.  New York: Basic Books, 1997.

Phil Klay, Redeployment. New York: Penguin, 2014.

Brett Litz, et al., Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review (2009), 29, 695-706.

Shira Maguen and Brett Litz, Moral injury in the context of war. U.S. Dept. of Veterans Affairs, National Center for PTSD (2015). http://www.ptsd.va.gov/professional/co-occurring/moral_injury_at_war.asp

William P. Nash, et al., Psychometric evaluation of the moral injury events scale.” Military Medicine (2013), vol. 178 (6), pp. 646-652. http://publications.amsus.org/doi/full/10.7205/ MILMED-D-13-00017#

Jonathan Shay, Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York: Scribner, 1994.