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Moral Injury and the American Soldier

I received a Combat Action Badge because, for a period of about a month in early 2004 in Iraq, I seemed to be a magnet for enemy fire. Random fire came close to hitting me on several occasions. After the last near-miss, I walked by some soldiers playing catch with a football on Forward Operating Base (FOB) Chosin, a base south of Baghdad in what journalists would later dub “The Deadly Triangle.” When they were behind me, one of them threw long over the hands of the intended receiver, and the football seemed to explode by my feet. I dove for cover behind some sandbags. Those soldiers laughed so hard that at least one was holding his stomach. As I got up, brushed myself off, and walked away sheepishly, one of them called out between laughs: “You’ll be all right, sir.”

Years later, explosions still cause me minor psychological discomfort. I can only enjoy fireworks from a distance. The sounds of gunfire and engines backfiring make me uncomfortable. But was I traumatized by enemy fire? No, I do not believe that I was. Not really. Perhaps the noise was never loud enough, nor the shrapnel quite close enough. What caused me to suffer today some symptoms typically associated with PTSD was not caused by extreme fear-producing hormones that affected the areas of my brain that regulate emotions, resulting in fears being linked to specific memories and perceptions. My actual sources of psychological distress do not meet the criteria for PTSD as described in the Diagnostic and Statistic Manual of Mental Disorders, the mental health community’s Bible. The unsettling nature of my most affecting combat experiences is primarily sewn together with a different thread, that of moral dissonance. When I look back at certain experiences, it is clear to me that others failed to make wise choices. It is obvious that I, too, sometimes failed to make the best decision. To our shame, we should have known better.

A growing number of mental health experts argue for the existence of a condition called “moral injury” that may better explain my symptoms than “PTSD.” Although moral injury is not listed in any edition of the mental health manual, many health experts argue that “moral injury” is real. In perhaps the most influential article written by mental health professionals on the subject, the condition is defined as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” According to these experts, while moral injury is often associated with PTSD, they are not the same thing. PTSD is physical in origin, while moral injury is a “dimensional” or “spiritual” problem. Events that are physically traumatic may cause PTSD; events that are not physically traumatic may serve as a source of moral trauma.  Many traumatic events may serve as a source of both PTSD and moral injury.

The two conditions share some symptoms. But there are also symptoms unique to moral injury, such as “shame, guilt, demoralization, self-handicapping behaviors . . . and self-harm.” They respond to different treatments: PTSD sufferers may be helped via such physical remedies as drugs and Rapid Eye Movement treatment. But those who have moral injury require counseling-based therapies.

Although moral injury is not listed in any edition of the mental health manual, many health experts argue that “moral injury” is real. 

Inner moral conflict is hardly unique to warriors. Those who fight wars just tend to feel it more deeply. In combat, they enter another world that is far removed morally from the one they grew up in. No longer are they always encouraged to show compassion toward others. The principle that they should treat others as they themselves would like to be treated must often be rejected. They do not want to be killed themselves, yet they must sometimes kill others. Compassion, the “Golden Rule,” and laws and mores that are normal at home are greatly modified on battlefields, applying to a warrior’s dealings with his comrades-in-arms but only in special circumstances to his interactions with “enemy” troops.

In the alien world that warriors enter, they may assume an identity—a posture toward large groups of fellow human beings—that seems just as alien and remote to them as the land and war in which they fight. This alien identity may or may not be something they can easily live with. This essay employs impersonal research as well as intimate personal experience to illuminate my core argument: Moral injury is real, and any nation or military that desires to truly honor its warriors must place perceptions of “what is right” at the forefront of its deliberations on when and how to wage war.

 

Moral Injury in Ancient and Modern Warriors

One afternoon in April 2004, I was in Baghdad talking on a military phone with my platoon leader at FOB Chosin. We were talking about a road running north from Chosin to Baghdad that was often closed due to roadside bombs. My platoon leader was enthusiastic about the plan she had worked out to catch the bomb emplacers, who mostly operated at night. This plan involved using as overwatch a ground surveillance radar, an older system designed to detect vehicular and foot traffic at night from a long distance away.

Her plan was exciting. There had been far too many buildings and vehicles in Baghdad, even late at night, to use these systems. This meant that an entire platoon of radar operators had been doing everything but the mission for which they had been trained. I knew her operators at Chosin had to be thrilled. Parked on a hill overwatching flat terrain, they might finally be able to protect soldiers and local Iraqis using their platoon’s organic equipment and skill sets.

She then told me that her soldiers were going to spend one afternoon physically reconning several possible overwatch positions. When she said that, warning bells went off.

Can’t you just do a map recon, I asked her. Or better, use Falcon View (a terrain mapping program) to find the best place for them to set up? I was comfortable, I told her, with her soldiers driving from FOB Chosin to a pre-selected overlook position. This would limit their potential exposure to roadside bombs. I wasn’t comfortable with them driving up and down what was probably the worst road for roadside bombs in Iraq looking for a place to set up the next day.

She was adamant. She said that the plan had already been briefed to the commander and operations officer of her supported infantry battalion. Both officers had agreed that the physical recon was a good idea, and infantry soldiers had been already detailed to provide an escort. Her platoon was attached to that battalion, and if I didn’t want them to go, I needed to take it up with this battalion’s commander.

She was technically correct. Her platoon—in military terms—was “attached” to that battalion. She took orders from that battalion’s commander, not me. I was supposed to ask questions, offer advice, help her acquire resources, and stay out of the way.

 Okay, I told her. I’m uncomfortable with your plan, but you’re the leader on the ground working with the leaders there. It’s your and their call.

That night, I went out with my human intelligence soldiers on an all-night cordon-and-sweep operation near Mahmudiyah, the town two years later made infamous by a group of rogue soldiers who raped a young Iraqi girl there, shot her and her family, and burned the bodies. When I returned exhausted to my company command post late the next morning, I heard the bad news: my soldiers at Chosin had struck a roadside bomb. Fortunately, no one was killed. Two were evacuated back to the states with extensive leg injuries, though their limbs were saved. Several suffered concussions.

I felt, and feel, responsible. I should have called that battalion commander and explained why the physical recon was unnecessary. He may have overruled me, but I should have tried.

Three years after that roadside bombing, I took a phone call in my office from a mental health professional on the other side of the country. She said that one of the six soldiers injured by this bomb was in bad shape due to severe PTSD and that she wanted to confirm the circumstances of his injury.

I told her what I remembered. When I got off the phone, I just sat silent there for several minutes while a wave of depression washed over me. I couldn’t help but wonder: if that soldier had had a better, stronger company commander, one who had had the moral courage to call and argue with that infantry battalion commander, would this soldier suffer from severe PTSD?

This question haunts me to this day.

 

“Moral injury,” Shay concludes, “is an essential part of any combat trauma that leads to lifelong psychological injury. 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.” The classics are rife with other examples of warriors suffering moral distress. When Oedipus, in the Greek tragedist Sophocles’ famous trilogy of plays, learns that he had unknowingly murdered his father and married his own mother, his sense of dishonor drives him mad, causing him to blind himself and wander raving in exile. Sir Thomas Malory’s Le Morte d’Arthur tells the story of Sir Lancelot and Guinevere, two lovers who, feeling their adulterous affair is responsible for King Arthur’s death, seek solitude and penitence for the rest of their lives. Many of Shakespeare’s warriors—motivated by feelings of grief or guilt—kill themselves, including Othello, Cassius, and, after seeing Caesar’s ghost, Brutus.The evidence supporting the existence of moral injury is voluminous and at least as old as the written word. Poets have long known that feelings of guilt and dishonor cause great distress to warriors and have chronicled the many miseries this distress can bring. The psychiatrist Jonathan Shay popularized the term “moral injury” in his 1994 book, Achilles in Vietnam: Combat Trauma and the Undoing of CharacterAt the heart of Homer’s The Iliad, Shay argues, is a story of sullied honor. Agamemnon, the Greek army’s commander, “betrays ‘what’s right’ by wrongfully seizing Achilles’ prize of honor,” the captured princess Briseis. Achilles is outraged at the slight, withdraws from the Greek army and the war, and “cares about no one but a small group of combat-proven comrades,” the Myrmidons. Consumed by anger, Achilles slowly withdraws even deeper inward, loving no one but his dear friend Patroclus. When the Trojan hero Hector kills Patroclus, “profound grief and suicidal longing take hold of Achilles.” Achilles “is tortured by guilt and the conviction that he should have died rather than his friend,” and “he goes berserk and commits atrocities against the living and the dead.”

The most famous sufferer of moral injury in literature may be the character of Kurtz in Joseph Conrad’s Heart of Darkness

One of Shakespeare’s most moving accounts of moral conflict in soldiers does not involve suicide. In Henry V, the young king visits a group of his men at a campfire on the eve of the Battle of Agincourt. Since Henry V is concealed by night and his cloak, his men feel free to complain about the war in his presence. In response to their complaints, the young, disguised king retorts that they should be more content, the king’s “cause being just.” A soldier replies, “That’s more than we know.” Another says: “Ay, or more than we should seek after; for we know enough, if we know we are the king’s subjects: if his cause be wrong, our obedience to the king wipes the crime of it out of us.” And a third talks about the “heavy reckoning” the king will pay if his “cause be not good,” thanks to all “those legs and arms and heads, chopped off in battle.” The young king leaves, shaken. Soon alone and on his knees, he passionately beseeches God to bless his cause and deliver victory, begging Him to remember all the good deeds he has done and will do for the poor and the church, if victory is delivered and, by this victory, his cause proven just.

The most famous sufferer of moral injury in literature may be the character of Kurtz in Joseph Conrad’s Heart of Darkness. Kurtz is the commander of a trading post on a river in the Belgian Congo. Initially an idealistic imperialist, Kurtz witnesses and perpetrates atrocities that rival those of Genghis Khan in type if not in scale. His soul becomes as afflicted as his body, which succumbs to jungle fever. As he dies, he seizes Marlow, the book’s narrator, and cries out madly at Marlow and Life: “The horror! The horror!”

In our era, literature’s observations have been supported by a plethora of psychological studies that link moral distress incurred by warriors in combat to enduring psychiatric conditions. Multiple studies of Vietnam veterans with PTSD found that many suffered from great feelings of guilt involving their combat experiences (see 19911997199820092010). These feelings were linked to PTSD and depression, sometimes abusive (even violent) actions, and such self-handicapping behaviors as drinking and suicide. A 2011 study involving 317 Gulf War veterans found that killing others is a significant predictor of PTSS [posttraumatic stress symptomatology], frequency and quantity of alcohol use, and problem alcohol use.”

The 2006 and 2007 Mental Health Advisory Team (MHAT) surveys of soldiers in Iraq and Afghanistan addressed both their mental health and battlefield conduct. The 2007 survey (MHAT V) found that “soldiers who screened positive for mental health problems were significantly more likely to report engaging in unethical behaviors,” though its authors did not theorize as to whether unethical behaviors contributed to the mental health  problems or vice versa. A 2010 study looked at the effect of killing others on 2,797 Iraq War veterans. The authors concluded that “killing was a significant predictor of PTSD symptoms, alcohol abuse, anger, and relationship problems.”) These studies’ conclusions are supplemented by a staggering amount of published anecdotal evidence. Dr. Shay’s, Dr. Nancy Sherman’s, Dr. Edward Tick’s, Dr. Rita Nakashima’s, and Dr. Gabriella Lettini’s work contain scores of veterans’ stories pointing to the same conclusions.

Some stories have gained much media attention. There is, for example, the sad tale of Alyssa Peterson, a young intelligence analyst who committed suicide in 2003 after being reprimanded for refusing to perform so-called “torture-lite” tactics. There is the tale of Levi Darby, who hanged himself in April 2007 because he felt guilty for the death of a little Afghan girl: he had gestured to the girl to come get a bottle of water, and when she came forward to get it, she was blown up by a land mine. There is the tale of Daniel Somers, who committed suicide in June of 2012. He had served as an interrogator and humvee gunner for two tours in Iraq. In his suicide note, he pointed to two main sources of distress, a government system that he said was not getting him the help he needed and “the war crimes” that he believed that he had participated in during his first tour in Iraq.

In his book, None of Us Were Like This Beforethe journalist Joshua Phillips tells how a group of soldiers at a small jail in Iraq tortured their detainees and how guilt over their deeds later tortured them. The abuse those soldiers inflicted included hanging prisoners from the bars of cages; depriving them of sleep, food, and drink; performing mock executions; making them perform painful physical exercises and assume stress positions; and beating, choking, and waterboarding them. When they returned home, many of these soldiers struggled with drugs and alcohol, insomnia, high blood pressure, depression, keeping jobs, and suicidal thoughts. They told Phillips that what bothered them most were their feelings of guilt. Two of them, Adam Gray and Jonathan Millantz, eventually died under circumstances their friends and families believe was suicide.

The evidence for the existence of moral injury is overwhelming. Moral injury causes mental torture to the very troops whose care is entrusted to American leaders. It leads soldiers to try to drown their sorrows in alcohol or the euphoria of drugs, to be involuntarily separated from the service due to disciplinary action, or to voluntarily leave the service—or the world, by killing themselves—because they feel they cannot cope anymore. It greatly burdens the U.S. military and civilian healthcare systems. It hurts the ability of veterans to positively contribute to society. It distresses and sometimes leads to the physical harm of those who interact with afflicted soldiers. Of all these adverse effects of moral injury, it is the role that moral injury may play in the U.S. military’s high suicide rate that has attracted the most attention.

 

 [This is the first part of a two-part article. The second part is here. The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. government.]

 

Lieutenant Colonel Douglas A. Pryer is an active-duty counterintelligence officer who has deployed to Kosovo, Afghanistan, and Iraq. He is the author of the book, The Fight for the High Ground: The U.S. Army and Interrogation During Operation Iraqi Freedom, May 2003 April 2004. The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. government.

 

[Photograph: The painting Thetis Bringing Armor to Achilles by Benjamin West. With his friend Patroclus killed, Achilles is inconsolable. He shuns food and others and vows to kill Hector.]

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15 comments

  1. Craig S. Carson 10 June, 2014 at 11:16 Reply

    This is the biggest piece of garbage I have seen in a very long time. I was a company commander in the infantry in the 173rd airborne in Vietnam, and was in frequent close combat with high casualties. Memories are painful, but they are the result of a soldier’s life. If you have a moral problem with war, you should be a conscientious objector not an officer. “Moral injury” PTSD is an offense to anyone who has actually been in combat.

    • Doug Pryer 17 June, 2014 at 03:42 Reply

      Mr. Carson,

      Should soldiers and the officers that lead them lack all conscience, so that, no matter what they do or see, they can remain untroubled by their own actions or those they witness during war? In the information age, in the wake of such moral and strategic defeats as Abu Ghraib, Gitmo, and Bagram replete with sickening images that flash around the world at the speed of light, is it wise to believe that our nation would be better served today or tomorrow by soldiers of less conscience, not more conscience? Would an army of brutal automatons–organic and inorganic machines–lead us to achieve greater success in the rest of the 21st century than we achieved at the end of the 20th century and the first decade and a half of this century?

      The answer to all these questions is no.

      Thank you for your service

  2. d 10 June, 2014 at 13:35 Reply

    Yes, so lets blame something that is not coded in the health care system, so there can be 100% denied compensation for disability resulting from PTSD.

  3. ML 10 June, 2014 at 14:40 Reply

    I am a retired psychologist who treated many combat Marines. I often found that the diagnostic criteria for PTSD was not met yet the patient suffered from an existential crisis, or moral injury as you describe. As providers, if we stuck to our guns and said he did not meet criteria for PTSD we were viewed as bad providers. Our conceptualizations that something different that PTSD was at the root and hence a different type of treatment indicated was challenged by many groups who support vets such as the Wounded Warrior Regiment and case managers. They wanted everyone diagnosed with PTSD. most Marines who were getting out wanted the diagnosis of PTSD yet they did not meet the criteria. Patients were then advised by case managers to seek a different provider to get the diagnosis of PTSD on their record . Often I would given them the diagnosis of Depressive Disorder NOS which was closer to their presentation that PTSD. Please keep up the good work to get the word out on the morale injuries and how this is NOT PTSD and it therefore needs a different treatment. Prolonged Exposure will not work for those with a moral injury and in my opinion that treatment can make the problem worse. Thank you

    • Doug Pryer 17 June, 2014 at 03:50 Reply

      Thank you, ML. I couldn’t agree more, and it’s good to see yet another psychologist who has extensive experience working with combat veterans saying much the same thing, adding his voice to the rising din.

      Is anyone listening, though?

      Regards,
      Doug

  4. Gregg Powell, LTC(Ret.), USA 10 June, 2014 at 15:25 Reply

    Exceptional article. This is a fantastic insight, and I believe a very accurate insight.

    regards,

    Gregg

  5. Ranger 39 12 June, 2014 at 03:09 Reply

    I am a retired Canadian Army Officer, Armour. I found your piece to be informative and well written. It touched on a number of points that I concur with. Perhaps this is Bias Confirmation or your points where on target. My war was long ago and involved working with a multi national forces including Americans. In my last job I had to bury lots of soldiers. That takes a lot out of you I found; stiff upper lip, soldier on, put on a brave face in the presence of adversity. Then try and make sense of it all when the home world is deeply fussed about the price of lettuce or who will win some foolish professional sports competition. Priorities and readjustment to different realities. I have not made the shift nor have many of my colleagues. The changes are perhaps to profound and you can not go back. Only forward. So pick up your weapon, put on your kit and start placing on foot in front of the other: Perseverance

    • Doug Pryer 17 June, 2014 at 04:04 Reply

      Thank you, Ranger. According to Dr. Jonathan Shay and others, moral injury tends to produce symptoms that are longer-lasting and more destructive than those of PTSD.

      I hope you’re right, about the stiff upper lip. I also hope you’ve been able to soldier on in civilian life, without feeling compelled to look over your shoulder too often at your own Sodom and Gomorrah, at your own war.

      Cheers,
      Doug

  6. Kevin 14 June, 2014 at 03:36 Reply

    I think it is operant conditioning vs moral injury. I feel more like Pavlov’s dog once the test was over. I don’t salivate when I hear a bell, but I do duck and cover whenever I hear the air defense warning system’s “incoming, incoming” alarm, or anything similar to it, when my mind is not in the here and now.
    Although I don’t like being near the launch point for a fireworks show. The mortars firing the fireworks sound just like those in Iraq.

  7. Anna 17 June, 2014 at 14:48 Reply

    As a veteran and currently my son is serving in Afganistan, I wonder if the enemy we are fighting and will continue to fight for a very long time also has so called “moral” injuries? Think about it. I am also dismayed that this administration has taken out class instruction to officers regarding the moral aspects of war and that war is sometimes necessary and right.

  8. Jake 7 July, 2014 at 15:32 Reply

    I’m not a soldier. Saying this I have not experienced war but I can relate to the concept. I’ve experienced the conflict between what I know is right and group/organization/situational correctness. It is a difficult mental process that can later become a personal issue. It is worthwhile for professional/researchers, to continue exploring. Good luck in this line of thought and work

  9. TK 6 August, 2014 at 14:47 Reply

    I never experienced close combat but directed the sinking of many of the Iraqi Navy in the Gulf War. At the end of the war we overflew several of the beached hulks and could see the terrific damage. It was at that point that it became quite clear that I had caused the deaths of many. There was an editorial several years later (I believe in the LA Times) that opined that our physically unscathed victors would suffer injuries to the soul. How true.

    I rarely think about it, but when I do, I wonder how I will be judged by Saint Peter. And worse now that my son is in the Navy, will he fall into this same trap?

  10. Dee G. 18 November, 2014 at 22:51 Reply

    Very thought provoking, I’ve just read your full essay on this subject and thought you may have missed something in your analysis: the training people go through to prepare them for what they have to do, weather as a face to face combatant or the drone operator. I don’t know what kind of training drone operators have, but I’m guessing it’s not the same desensitization that infantryman go through. I just thought I’d point to this possible difference – it may have some implications around the issue of moral injury, and also this very new reliance on drone strikes.

    Forgive me if I used any wrong terms, I have no military connections whatsoever, I’m just a concerned citizen.

    • Doug Pryer 6 December, 2014 at 17:52 Reply

      Dee G, you’re right: Drone operators don’t go through the same degree of desensitization (dehumanization) that infantry soldiers or special operators experience. I wouldn’t make too much of that distinction, though. In my own experience, while military training can deepen certain personality tracks that have already been worn within you while helping you to fill in some others, it doesn’t entirely remake you. I know I for one didn’t feel any major change occurring when going through basic training during bayonet training and chanting, “What makes the grass grow? Blood, blow makes the grass grow!” I still felt essentially myself–the same soul looking out at the world, trying his best to make sense of things–and I really don’t think this would’ve changed if I had followed basic training with infantry school.

      In short, the transformation of citizens into sharply dressed killers is at best an onion layer on the “self,” easily peeled, more appearance than reality.

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