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‘Moral injury’ gaining traction, but still controversial

Filed by KOSU News in Public Insight Network.
June 26, 2013

One after another, veterans would come in to Jonathan Shay’s office with stories of a death they couldn’t shake. Some were events you’d expect during a war; others were unthinkable, unforgivable and haunting. Most of these stories were not part of the veteran’s combat medical history. Shay, a psychiatrist at the Department of Veterans Affairs clinic in Boston, would add them.

There was the Marine corporal who ordered subordinates to help him gun down 17 disarmed Vietnamese after his commander had told him, “We don’t need no prisoners.” The corporal, a Catholic, had to goad his men to participate. Years later, he had become a gutter drunk, Shay says, convinced he’d “led his men into mortal sin.”

Shay remembers the story of a Marine scout sniper who couldn’t stop replaying a particular moment during the assault on Fallujah in Iraq. A well-hidden enemy sniper had hit several members of the Marine’s unit. “When the scout sniper finally located his enemy sniper in his scope,” Shay explained, “he realized that he was wearing what we would call a ‘snuggly’ baby carrier. There was a baby strapped to his front.”

The Marine killed the sniper and the baby.

“His view of his duty to his brother Marines and his job description was to take the shot,” Shay said. “It’s part of a terrible curse of snipers that they actually see their weapons doing their work. He took the shot and it did its work and he’s going to live with that for the rest of his life.”

Constructing a pattern

The veterans who came to see Shay were living with these memories, but they were not at peace. After hearing similar stories, again and again, Shay constructed a pattern: A soldier betrays his or her sense of what’s right, under orders, in a high-stakes situation. By the mid-1990s, he started calling the condition that results “moral injury.”

Dr. Jonathan Shay describes the three elements of moral injury: A betrayal of your sense of right and wrong by someone who holds legitimate authority -- in a high-stakes situation (Photo by Martha Bebinger | WBUR)

Dr. Jonathan Shay describes the three elements of moral injury: A betrayal of your sense of right and wrong by someone who holds legitimate authority — in a high-stakes situation (Photo by Martha Bebinger | WBUR)

Imagine someone you trust, telling you to do something that you feel is deeply wrong, in a possible life-or-death situation. And you do it. “You will discover your body reacts,” Shay said. “Your guts churn, your heart begins to pound, you may get sweaty. It’s a horrible thought experiment.”

The experience is not new. Shay says the concept of moral injury comes right out of the “Iliad” and thousands of years of war. But it’s not an established condition. Shay, a 2007 MacArthur “genius grant” recipient, has been writing and lecturing in an effort to change that.

“I describe myself as a missionary from the veterans that I’ve served,” Shay explains. “They don’t want other young kids wrecked the way they were wrecked, so listen up.”

Shay urges military leaders, members of Congress and audiences across the country to support three changes he says would help prevent moral injury:

  • Send troops “into danger together and bring them home together.”
  • Provide better training and support for military leaders.
  • Make training for all troops “prolonged, cumulative and highly realistic.”

Shay says when he lobbies for these changes he might get a hearing, even in front of top military leaders, but pressing his case has been “a lonely pursuit.”

That’s changing, as a growing number of researchers are focusing on moral injury.

“Shay started the ball rolling, using literature to raise the consciousness of care providers and families,” said Brett Litz, a clinical psychologist with the VA’s health care program in Boston and a professor at Boston University. Now Litz and his colleagues are attempting to build out the science.

Studies of active-duty soldiers and Marines are underway to determine for the first time how often moral injury occurs, what it looks like and how to treat it. At Camp Pendleton in California, Marines who suspect they have post-traumatic stress disorder, or PTSD, come in for therapy and are asked this question:

What is the most currently distressing and most haunting experience that you had in multiple deployments?

Researchers use the question “to get at their sort of principle wound, if you will,” Litz explains.

Litz says when you sort Marines’ responses to establish their main wound, only about one-third actually have PTSD or anxiety from a traumatic, often life-threatening event. Another one-third focus on loss, often the death of a close friend. And the final one-third describe a moral injury.

Brett Litz, a psychologist at the Department of Veterans Affairs hospital in Boston, is a lead researcher on moral injury. (Photo shared by Brett Litz)

Brett Litz, a psychologist at the Department of Veterans Affairs hospital in Boston, is a lead researcher on moral injury. (Photo shared by Brett Litz)

Litz says of these three groups, Marines with a moral injury appear most at risk for hurting themselves.

“Self-harm might arise because you feel unforgivable and damned and you may feel at a very deep level that you deserve to suffer,” Litz says. “So how is someone going to behave if they feel that they deserve to suffer? They may abuse drugs, they may drive dangerously, some may not even care whether they live or die.”

Marines with a moral injury or those mourning a loss may also feel hopeless, Litz says. Others actively sabotage their lives.

“If you feel undeserving and unforgivable, you may take one step forward in your relationships and your workplace and then three steps back,” Litz says. “You may feel guilty if you feel good.”

Litz is in no rush to turn moral injury into a medical condition, but he and his colleagues are testing a treatment with Marines on the base.

“We want to promote — to a degree — a confession-like experience,” Litz says. “We do this in a highly evocative, highly emotionally charged way. We want it to be very real and very powerful.”

In this charged moment, a Marine begins a conversation with his or her most compassionate, forgiving loved one — someone who will listen to all the horrible details of the Marine’s injury and still remind the Marine “that they can have goodness in their life,” Litz explains. “That they deserve it but that they have some work to do. And it’s the work to do which we’re just setting in motion.”

It’s work that may continue for years in therapy, in volunteer work and maybe in a church, synagogue or mosque.

Litz says he’s proud that the military is funding such controversial research.

“It’s controversial to think that war can be damaging about morality,” Litz explains. “After all, service personnel are ordered to do what they do, and they’re trained to do what they do. So how could it be damaging, morally and ethically? And we were funded by the military to do this larger trial, which I think is extraordinary, just extraordinary.”

Moral injury, or inner conflict

But funding research about moral injury doesn’t mean the Marines Corps has embraced the concept.

“Marines don’t like to say, ‘I’m being injured by doing the very thing I’m being trained to do,’ ” says Navy chaplain Mark Smith, who helped negotiate the official doctrine on moral injury for the Marine Corps in 2008.

In short, the Marines adopted the concept, but renamed it “inner conflict.” Marines would tell Smith, “I understand I can get injured while I’m doing the thing I’m trained to do, but when you say the thing I’m trained to do injures me, some of them at least struggle with that. So we avoided [the struggle] by sticking with inner conflict.”

Navy Capt. Mark Smith, a chaplain, says Marines prefer the term “inner conflict” to “moral injury” when talking about unresolved feelings about war. (Photo shared by Capt. Mark Smith)

Navy Capt. Mark Smith, a chaplain, says Marines prefer the term “inner conflict” to “moral injury” when talking about unresolved feelings about war. (Photo shared by Capt. Mark Smith)

Changing the name makes the concept more acceptable for Marines who need help, says Navy commander and clinical psychologist Andrew Martin. He used to direct the Marines’ suicide prevention program, and is now in charge of expanding community counseling and prevention programs at bases across the country.

“One of the goals of prevention is to get Marines talking to each other early about problems,” Martin says. “The Marines told us that the term ‘inner conflict’ resonated much more with them and they found that facilitates, more easily, conversations with one another.”

Using one term in Marine Corps programs and another in research surveys and test treatment can be confusing. It’s a sign that moral injury is an evolving, not yet settled, condition. But Smith says the concept is gaining traction.

“I think it’s taking hold. I think people are paying attention and recognizing this is something we need to understand much better — and we need research to back it up,” he says.

Martin says the military understands that any stressful situation — including moral injury — has the potential to increase somebody’s risk for suicide. But he says rising suicide rates within the military go beyond any single factor.

“When dealing with suicide prevention, the important thing to keep in mind is that we have to consider all variables,” Martin says. “So if this is one, it’s important to address just like all others.”

Some veterans argue they’re not the only ones who need help, forgiveness and healing. Former Marine Capt. Tyler Boudreau says responsibility for all the times he gave a sniper permission to fire goes right up the chain to his commander and beyond.

“To what extent do you have responsibility for me giving permission to a soldier to shoot a person in Iraq?” Boudreau says.

Boudreau isn’t just posing that question, he’s also asking all of us to share the burden of moral injury and help find ways to heal. We have to start, Boudreau says, by talking.

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