Veterans Must Also Heal From Moral Injury After War

As the national tragedy and disgrace of veteran and active military suicides continues – some 22 die by their own hand each day – we must do more than happily wave an American flag at a Veteran’s Day parade or thank a veteran for their “service.” How we characterize the injuries sustained by veterans in war is crucial both to our understanding of the experience and to the healing process. So-called “invisible wounds” of war are complex and multifaceted and to ignore, trivialize, subsume or pathologize the totality of veterans’ readjustment difficulties under the clinical diagnosis umbrella of post-traumatic stress disorder (PTSD) is misguided and fails to address the full spectrum of veterans’ injuries and needs.

For purposes of clarity and accuracy, I have termed the totality of the invisible wounds presented by returning veterans not as mental illness but as Combat-Related Psychological, Emotional and Moral (CRPEM) injuries of war. Therefore, what is required to assist veteran recovery is a comprehensive and holistic treatment program that includes but goes beyond PTSD; that is, beyond traumatic stress, and deals as well with the detrimental effects of war upon one’s moral character and integrity: moral injury.

As a former Marine Corps officer, a CRPEM-injured veteran of the Vietnam War, and a philosopher whose life’s work has focused upon war and morality, I have been writing and speaking about moral injury for many years now, even before the idea gained mainstream traction.

When I first presented my ideas — subsequently published in the International Journal of Applied Philosophy — to a physicians and clinicians’ Grand Rounds at the Veterans Administration Medical Center in Brooklyn, New York, I was told rather brusquely that morality is clinically irrelevant to therapeutic practice and veteran healing. Fortunately, over the years, more enlightened clinicians have realized that transgressing a deeply seated sense of self — what I term one’s “moral identity,” as is commonplace in war — can have serious and lasting detrimental consequences.

Moral Identity and Moral Injury

Humankind has identified and internalized a set of values and norms through which we define ourselves as persons, structure our world and render our relationship to it — and to other human beings — comprehensible. These values and norms provide the parameters of our being: our moral identity. Consequently, we now have the need and the means to weigh concrete situations to determine acceptable (right) and unacceptable (wrong) behavior.

Whether an individual chooses to act rightly or wrongly, according to or in violation of her moral identity, will affect whether she perceives herself as true to her personal convictions and to others in the moral community who share her values and ideals. As the moral gravity of one’s actions and experiences on the battlefield becomes apparent, a warrior may suffer profound moral confusion and distress at having transgressed her moral foundations, her moral identity.

Guilt is, simply speaking, the awareness of having transgressed one’s moral convictions and the anxiety precipitated by a perceived breakdown of one’s ethical cohesion — one’s integrity — and an alienation from the moral community. Shame is the loss of self-esteem consequent to a failure to live up to personal and communal expectations.

First Things First: Lessening the Stigma

An important first step in the treatment of all CRPEM injuries is to create an environment in which current and former members of the military can feel comfortable seeking treatment, assured both that their injuries will be taken seriously and that they will be treated with dignity and respect.

An effective way of lessening the perceived stigma attached to seeking treatment is to reject the pathologizing of CRPEM injuries as “mental illness” — that is, its clinical designation as PTSD, rather than, say, as battle fatigue, combat exhaustion or shell shock, and as such, its disconnect from the combat experience.

Further, CRPEM injuries must be acknowledged as a direct consequence of war fighting and as much a combat injury as a battlefield bullet wound or shrapnel-broken tibia. To say otherwise betrays either an effort to disenfranchise the psychologically, emotionally and morally injured, or an ignorance of the nature, prevalence and severity of these non-physical injuries.

Consequently, the CRPEM-injured must be recognized as combat-wounded and therefore eligible to be awarded the Purple Heart Medal. To do so would send the message to veterans and members of the military community — many of whom give only lip service to the severity of such injuries — that CRPEM injuries are real and legitimate wounds of war and not the source of shame and embarrassment.

Most importantly, it would do much to lessen — perhaps even end — the perceived stigma of mental illness and encourage current and former members of the military to recognize, accept and seek treatment for their injuries.

Dialogue-Based Intervention

As trauma certainly remains a significant aspect of the war experience, an encompassing and holistic approach to treating the full spectrum of CRPEM injuries may well include traditional and nontraditional clinical intervention for traumatic stress.

These therapies have, for the most part, however, proven less than effective in treating CRPEM injuries, particularly moral injuries. As an alternative, I offer what I term “Dialogue-Based Intervention” (DBI), a treatment modality utilizing philosophical techniques and insights that are well-suited to assist veterans, particularly those suffering from moral injury, to achieve “healing.”

I put healing in quotes because, given the pervasiveness and life-altering effects of war, the healing we are seeking in DBI (or from any treatment modality) is not a return to some unrealistic prewar innocence (as healing in that sense may not be possible), but readjustment, to restore a level of normalcy to veterans’ lives by rendering CRPEM injuries less toxic. Moreover, DBI healing would provide a means for the afflicted to achieve a moral stasis or equilibrium — to accommodate and to find a place for the injury in their being, and ultimately, to build a life around it.

As groups of five to eight veterans begin the DBI process, the initial focus will be on the critical task of building a group dynamic of trust and mutual respect. Also during this time, the veterans become familiar with the theoretical philosophical and psychological ideas and concepts relevant to providing the parameters of their moral identity, a measure of clarity regarding their military and battlefield experiences, and, ultimately, an answer to important existential questions like, “What have I become?” and “Who am I now?”

Foundational to moral injury are issues of meaning, value, and of personal, ideological and moral conflict precipitated by the veteran’s experiences in war — all of which are particularly well-suited to being addressed philosophically. Specifically, DBI assists the veteran to understand the theoretical nature of war — its moral, social and political underpinnings — the profound indoctrination process he has endured, the nature of moral values and the existential reality of war — all of which are essential to addressing the seemingly irreconcilable moral conflicts inherent to the battlefield.

For purposes of clarity, I will explain DBI as encompassing a series of distinct “healing phases.” In reality, however, these phases may certainly overlap, and how the process proceeds and the gains achieved will depend upon a number of variables, such as the group’s cohesion, the specific needs of the individuals involved, and perhaps most importantly, their willingness to engage with particular issues and aspects of the experience.

Healing Phase One: Focused Moderated Dialogue

Human beings are not killers by nature. In boot camp and basic training, late adolescents and young adults are programmed to kill in war through a sophisticated process of operant conditioning, indoctrination and value manipulation to effect what I term “moral identity transition” from civilian, with its appropriate values and behaviors, to the values and behaviors of a warrior who will kill upon command, an identity reinforced by their experiences on the battlefield.

Consequently, DBI begins with moderated dialogue aimed at enabling the veterans to understand the programing, value manipulation and indoctrination they’ve endured, and the mythology of nobility and honor they’ve embraced as recruits during boot camp/basic training and as warriors on the battlefield.

With this awareness, veterans begin to understand that life amid the violence, death, horror, trauma, anxiety and fatigue of the battlefield undoes character, undermines one’s ethical foundations and moral integrity, erodes their moral being, rendering judgments of right and wrong — morality — irrelevant, and makes people capable of incredible cruelty and atrocity that would never have been possible before being victimized and sacrificed to war.

Healing Phase Two: Guided Introspection

The next phase involves what can best be described philosophically as moral dialectic. Through guided introspection, veterans seek to resolve the internal conflict between their now-dysfunctional warrior values and principles contradicted by the remnants of their foundational moral values and principles that survived the indoctrination process — their pre-warrior ego and moral identity — the violation of which now informs the shame and guilt indicative of their moral injury.

Once having done so, veterans can begin the process of synthesis, eventually determining a moral identity that embraces values and behaviors appropriate to the non-martial society into which they are to reintegrate. This Hegelian dialectic functions as a reverse boot camp, so to speak, intended to clarify and shore up their moral identities and verify that this period of horror — their time on the battlefield — was a moral aberration, and that their doubts and questions regarding their participation in and behavior during war were well-founded.

Healing Phase Three: Remembering, Reasoned Analysis and Reassessment

Having completed the necessary philosophical and psychological groundwork, veterans can now begin the very difficult task of confronting the experience. That is, of remembering, reassessing and morally reevaluating their responsibility and culpability for their perceived transgressions on the battlefield.

Reassessing their behavior in combat within the parameters of their increased philosophical and psychological awareness, veterans realize that the programming to which they were subjected and the experience of war as a survival situation are causally connected to those specific battlefield incidents and behaviors, theirs and/or others’, that weigh heavily on their consciences — their moral injury. As a consequence, they understand these influences as extenuating circumstances.

Finally, as they morally reevaluate their actions in war, they see these incidents and behaviors in combat not as justifiable, but as understandable, perhaps even excusable, and their culpability mitigated by the fact that those who determined policy, sent them to war, issued the orders, and allowed the war to occur and/or to continue unchallenged must share responsibility for the crimes and horror that inevitably characterize war.

Phase Four: Atonement, Absolution and Activism

Given the moral gravity of the war experience, the journey to “healing” is often long and difficult. After reassessing and reevaluating their behavior on the battlefield, veterans may, in some instances, determine their guilt and shame appropriate and impossible to reason away.

It is not uncommon, then, for CRPEM injuries to persist, causing veterans to feel that renewal and redemption — atonement and absolution — is necessary for “healing” and to once again rejoin the moral community of humankind. After all is said and done, in such situations, self-forgiveness for their unresolved transgressions may be necessary, whether through religious ritual (confession, sweat lodges, etc.) or through acts of atonement (community service or speaking to students, civic organizations and other groups about the nature and reality of war).

It is at this crucial juncture in the healing process that veterans realize the importance of activism. By speaking out, educating the public about the truth of war, exposing militarists’ lies and holding them accountable, working for the well-being and dignity of their comrades still in harm’s way, and for the betterment of humankind, many veterans can (and have) found the penance, absolution and renewal they so desperately need to forgive themselves and go on with their lives.

Ultimately, what is crucial to “healing” is that guilt and shame not remain static, veterans’ personal and private burden. While the past can never be undone, nor the dead be made to live again, activism may allow the veteran, if not to assuage his shame and guilt, at least to frame some sort of life around it.

The goal is that such acts of atonement restore the veteran’s sense of integrity, his moral cohesion, and in so doing, to build his self-esteem and perception of self. Further, re-establishing his moral identity will restore intelligibility to the veteran’s world, their relationship to it and to other human beings, thereby enabling re-integration — ending their alienation and isolation from the remainder of the moral community.

Despite greater understanding of the injuries sustained in war and more effective and focused treatment modalities, as long as the killing and dying continues, many more veterans and active military will become CRPEM casualties. And many more will die by their own hand to end their suffering. Ultimately, what is required to fulfill our obligations to veterans is to end perpetual war and that we bring our soldiers home now and adequately care for their injuries upon their return.