A New Theory of PTSD and Veterans: Moral Injury

In a series of pioneering studies, one researcher found that, from World War II to today, killing was the single greatest risk factor for PTSD, bigger even than heavy combat. Alex Majoli / Magnum for Newsweek

They called themselves the Saints and the Sinners, a company of Marine reservists from the Mormon land of Salt Lake City and the casino shadows of Las Vegas. They arrived in Baghdad a day before Iraqis danced on a fallen statue of Saddam Hussein, and as they walked deeper into the city, they accepted flowers from women and patted children on the crown. Then their radio operator fell backward, shot in the head.

Perhaps 5,000 rounds followed in an undulating crosscurrent of gunfire and rocket-propelled grenades. At a five-point intersection near the headquarters of the Republican Guard and Defense Ministry, the men of Fox Company—Second Battalion, 23rd Marine Regiment—dug in. They aimed at everything, because everything seemed to be aiming at them. From second-story windows and around corners, they fired into the road. Their bullets broke windshields, pierced soft flesh, and exited into seat cushions. At least three enemy vehicles broke through the American barricade. The company’s radio failed, cutting them off from reinforcements, and a grenade bounced behind their line—a dud, or the casualties might have been even worse.

Although all the men in the unit came home alive, many came home changed. Within five years, one in four had been diagnosed with posttraumatic stress disorder. Today one in two of them carries debilitating psychic wounds, according to an estimate by the men. They are jobless, homeless, disposed to drugs and alcohol, divorced from their spouses, and cut off from their former selves. One made love to his girlfriend, the mother of his twin daughters, then immediately drowned her in a warm bath. If you ask the military and mental-health establishment what happened to the men of Fox Company, the answer is simple: they lived through “events that involved actual or threatened death,” felt “intense fear,” and like the 300,000 other service members who share this narrow official path to PTSD, they were badly shaken by it.

But as clergy and good clinicians have listened to more stories like these, they have heard a new narrative, one that signals changes to the brain along with what in less spiritually challenged times might be called a shadow on the soul. It is the tale of disintegrating vets, but also of seemingly squared-away former soldiers and spit-shined generals shuttling between two worlds: ours, where thou shalt not kill is chiseled into everyday life, and another, where thou better kill, be killed, or suffer the shame of not trying. There is no more hellish commute.

When they came home from the war, members of the Fox Company brought the fear with them, according to the conventional view of PTSD. They tried to stuff it, marriages exploded, careers disintegrated, and then a door slammed, or a kid shrieked, and they were back in the intersection, a sweaty, palpitating mess. Since PTSD entered the pantheon of official disorders—at first it was called Post-Vietnam syndrome—this “fear-conditioning” model has pushed out all others. It was developed by shocking lab animals, then soothing them back to some level of normal squeaking and scratching.

And for many veterans, the resulting treatments—a pill, a course of talk therapy—work just fine. But despite three decades of research and billions of dollars in government funding, America’s servicemen and -women are not getting better. They are getting worse. Self-harm is now the leading cause of death for members of the Army, which has seen its suicide rate double since 2004, peaking this past summer with 38 in July alone. But the risk to discharged veterans may be even greater. Every month nearly 1,000 of them attempt to take their own lives. That’s more than three attempts every 90 minutes, at least one of them successful. Every time the credits roll in a movie, or the postgame show begins, another veteran is dead. “It’s an epidemic,” Secretary of Defense Leon Panetta admitted to Congress this summer. “Something is wrong.”

Military leaders have pointed to alcohol, guns, and girl trouble. The secretary of Veterans Affairs recently suggested wider societal woes, noting that suicide is up for all young men and women. But new ideas are vying for legitimacy, a whole new theory of war’s worst ravages. It’s called “moral injury,” and it comes from clinicians who spend their days speaking with soldiers who have been in battle. These veterans rarely mention fear. Instead they talk about loss or shame, guilt or regret. They had tried to be heroes, to protect the weak, save their buddies, take the hill. But then they mistakenly killed civilians, forced themselves to drive past wounded children, sometimes missed their moment of truth. Even after the Battle of Fallujah, in 2004, where William Nash served as a combat psychiatrist, fear wasn’t a factor. “Survivor’s guilt, moral injury, feeling betrayed by leaders,” says Nash, the lead author of the current Navy and Marine doctrine on stress control, “That’s what I saw every day.”

Now, along with some of the most distinguished doctors in the Department of Veterans Affairs, he believes that moral injury and its sister, traumatic loss, may be the “something” Panetta is looking for: the leading cause of PTSD, depression, substance abuse, and even the military’s epidemic of suicide. If so, it’s a radical idea. It shifts the focus onto what service members do to others, or in some cases fail to do for each other—not what gets done to them. Perhaps most controversially, it allows for the fact that war itself, no matter how just or good, will leave many of the men who fight it feeling like they’ve dirtied their souls, and perhaps for a simple reason: there is just something about killing that bites the conscience and doesn’t let go. “I don’t want to use it as a crutch,” former lance corporal Walter Smith, the member of Fox Company who murdered the mother of his children, said in a prison interview in 2008. “But I know for a fact that before I went to Iraq, there’s no way I would have taken somebody else’s life.”

Veteran's Day Military leaders reject the idea of moral injury—one advised the suicidal soldier to “be an adult.” Ed Kashi / VII

Last month Lu Lobello, a machine gunner with the Saints and the Sinners in 2003, traveled to Washington, D.C., to speak to a panel at the Newsweek and The Daily Beast Hero Summit. To an audience of mostly civilians in business casual, he revived his memories of that battle in Baghdad. By way of introduction, the moderator, Wolf Blitzer, said that Fox Company had killed three civilians in the crossfire. “Well,” said Lobello, “first off, there were about 20 innocent civilians, not three.” He then limned the rest of the raw story: many of the cars in the intersection held families, not fighters. When the Marines realized this, they tried to help, but often it was too late. Another car would come, and they would shoot it, because what if this one was the enemy. “We were shooting at civilians,” his superior officer explained to a reporter in 2008. “We were taking out women and children because it was us or them.” The image that stays with Lobello is one of the first from that day, of a fellow Marine walking in tight circles, talking to himself. “We shot a baby!” he screamed, turning to Lobello. “Lobello, we shot a baby!”

Moral injury is as old as war. It is recognizable in the Iliad and the Odyssey, and in the oldest surviving play of Sophocles. It’s hidden in the private thoughts of soldiers from every prior American war. It was perhaps first used in the journals of Mac Bica, a Vietnam vet turned philosophy professor. In the 1990s two more Ph.D.s popularized the idea, describing the “the psychological burden of killing” and the Homeric betrayal by leaders. The common thread is a violation of what is right, a tear in what some people freely call the soul.

And yet what might be intuitively true—that soldiers live to regret, in agonizing duration and detail, what war forces them to do—has until now not been part of official knowledge. When Lobello and the men of Fox Company came home, in 2003, they went from the war zone to their front doors in less than a week. Their mental-health screening was pro forma: a group of them in a room, some questions, and a long form to fill out. Are you OK? Yes? OK, thank you. Next!

In the years that followed, however, more VA doctors began to notice that veterans were deteriorating; by mid-decade the picture was grim: one in five soldiers with PTSD or major depression, one in two veterans who report to the VA, looking for help with their mental health.

Brett Litz, a clinical psychologist at the VA Boston Healthcare System, noticed something else: the existing treatments for PTSD may not be enough. In case after case, they failed to improve veterans’ conditions to the extent that they helped civilians’. Litz wondered why. As the wars in Iraq and Afghanistan entered their second halves, he also noticed that while clinicians were trained to hear stories of fear, when he spoke with veterans, what they mainly heard about was sadness. There was sadness related to loss, but also sadness he attributed to “bearing witness to evil and human suffering and seeing death and participating in it.”

On the other side of the country, his colleague Shira Maguen, a clinical psychologist at the VA San Francisco Healthcare System, was having similar thoughts. She began to look for a connection between killing in combat and PTSD. She found that in these wars, much as in Vietnam, more than one in three soldiers reported killing the enemy; other researchers found that one in five acknowledged killing a civilian by mistake; two in three handled or uncovered dead bodies, and the same ratio saw wounded and sick women and children they couldn’t help. Nearly 80 percent had lost a friend or had a friend wounded.

No wonder they were feeling heavy with grief and guilt. Looking at the data, Litz says it seemed “unequivocally clear” that the fear model was not enough. In 2009, he joined with Nash, Maguen, and two others to publish “Moral Injury and Moral Repair in War Veterans.” They called urgently for further study to fill a “clinical care vacuum” that is “doing a disservice” to service members. “These are people who 
have fought hard to come back alive, and they end up turning the gun on themselves,” Maguen says today. “We owe them better.”

The American military has been called “the world’s best killing machine,” and yet the word killing is the last thing you’ll hear the military discuss. The word doesn’t appear in training manuals, or surveys of soldiers returning from combat, and the effects of killing aren’t something the military screens for when service people come home. It’s strictly a private word, something hissed about in bars and between bunk beds.

But it might also be a public scourge. In a series of pioneering studies, Maguen found that from Vietnam to today, killing was 
the strongest or near strongest risk factor for PTSD, even when taking heavy combat into account. She found that among Vietnam vets, killing in combat doubled the risk of suicidal thinking. In veterans 
of Iraq, killing not only predicted PTSD but alcohol abuse, marital problems, and anger-management issues. As many as one in four veterans develops a drinking problem; one in three shows signs of depression. She says she hears some lines repeatedly in clinic: “Nothing can prepare you for what it’s really like,” some say. “It feels like I’ve lost my soul.”

In another study, William Nash looked at the effects of combat on about 200 Marines involved in heavy fighting in Afghanistan in 2009 and 2010. Three months after coming home, interviews showed that 15 likely had PTSD linked more closely to guilt than to fear for their lives. Killing is obviously one source of guilt. Another is failing to save a comrade. One prior study of veterans found that surviving a friend in combat is tied to more severe symptoms of grief than losing a spouse, even 30 years later, and even if the spouse died in the last six months. Litz calls all this a “no-brainer hint” that loss and moral injury “is going to explain a big chunk of why veterans suffer.”

The departments of Veterans Affairs and Defense seem prepared to agree, and have backed a four-year study of moral injury in Marines. In San Francisco, Maguen is testing a program aimed at relieving the after-effects of ending a life. Litz, meanwhile, is testing a loss-and-moral-injury intervention on Marines. For both clinicians, the focus is on education, compassion, and forgiveness. The sessions take service members on a journey that may include letters to the dead or imaginary conversations with a superior officer, someone in a position to say the suffering may end.

The idea has already caught on beyond the medical world. The Center for Soul Repair opened last month at the Brite Divinity School at Texas Christian University. It’s a five-year effort to train the nation’s religious leaders, as well as the public, to respond to moral injury. In New York State, Edward Tick, the author of War and the Soul, created solider-to-soldier listening groups called Soldier’s Heart; there are nearly 20 nationwide.

But moral injury is still a long way from the mainstream. It isn’t considered an official diagnosis by the VA or the American Psychiatric Association. The framers of the 2013 Diagnostic and Statistical Manual of Mental Disorders were persuaded to add guilt and shame to the symptoms section of PTSD but haven’t changed the cause—and thus the official focus of treatment. It remains fear. And probably will remain fear for the foreseeable future. To the military, Nash explains, “just using the term is somehow pejorative ... They think we’re saying they’re immoral. But the exact opposite is true. It’s because soldiers have such high standards that they’re vulnerable to moral injury.”

The message has yet to sink in. Last year at a national gathering of military personnel and mental-health experts, Litz and Nash shared a stage with a Marine lieutenant colonel, who told the men he was “insulted” by the term moral injury. It’s understandable why the military would flinch. If feelings of guilt or sinfulness are recognized as normal reactions to participating in war, what does that mean for the people sending young men down-range? Where does the stain stop? Does it ever?

There’s already a soul-repair role here for friends and family, a big one. Karl Marlantes went to Vietnam, won the kind of medals that get him free drinks, and came home haunted by some of the lives he took. In his 2011 memoir, What It Is Like to Go to War, he argued for the end our chirpy, parade approach to veterans, which he compared to clapping for a surgeon who has just amputated a leg.

“This ain’t a football game,” he explained by phone. “We’re talking about killing people here.”

He wants “a solemn parade,” a recognition of the moral damage we all suffer when we send our fellow citizens into battle, and a willingness to talk about it—good, bad, and ugly. But instead most of us offer wan thanks, pushing veterans away from us and inside themselves, until their world narrows into a binary choice: go to war and maybe die, or stay at home and feel dead already. It’s no choice at all.

None of this new thinking can change the past for the Saints and the Sinners of Fox Company. But it might be able to remake it, giving name to something that has been mislabeled or ignored, and changing the way people understand the veterans in their lives, not only today but back through the decades.

Additional reporting by Alison Snyder

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