Military Begins to Acknowledge Moral Injury

Gruesome and heroic war stories may sell a lot of movie tickets, but in real life, soldiers seldom like to talk about their experiences on the battlefield. At least not with civilians. This silence is also a trait of veterans who suffer from Post-Traumatic Stress Disorder.

Today some in the Department of Veteran’s Affairs say psychological damage from particularly egregious war violence, like killing children or seeing friends killed, can create an affliction of the soul.

Serving in Operation Iraqi Freedom in 2004, Army Sergeant First Class Robin Johnson’s platoon was running a routine traffic check point, hoping to catch people carrying bombs or explosives in their vehicles. Suddenly, a car comes out of side street. It speeds up and heads straight towards them.

“The window of signaling, shooting for a warning shot, shooting to disable and then engaging can be milliseconds. You have to make that judgment call of – is this a threat?” Johnson says, 

Then Johnson’s platoon engages. He is one of the first to fire.

“Once it was done, it was just a family,” he says. “You know, a mother, father and infant in the mother’s lap, and then two little girls in the back seat.”

Johnson relives that day over and over again, often angry at the father, wishing he could ask him these questions:

“You know, why didn’t you just stop? Like why didn’t you stop? What was his logic was he trying to get down the next side street? Did we scare him?  What was going on in his head at that moment?” Johnson says. “Now this whole family is gone. They got up that morning and they ate breakfast together. They talked and they laughed and they planned out their day. And now they’re gone.”

“What makes a warrior a warrior is taking personal responsibility. And when they fail to live up to that enormously high idea, that’s Moral Injury,” says retired Navy psychiatrist William Nash.

Nash helped pen the latest “Marine and Navy Combat Operational Stress Control Doctrine,” which is basically the mental health bible for military leaders. Nash says it includes, for the first time, the concept of damage from Moral Injury within a PTSD diagnosis.

And it wasn’t easy for therapists, he says, “to be asking veteran service members after they come back from a war zone about events where they did things that maybe they were told to do, maybe they had to do, that in the context of a crazy counter insurgency war, were the right thing to do, that they now feel were unacceptable.”

Nash says the idea, the acknowledgement and – yes – even the words are a tough hurdle for the military. But, by acknowledging that Moral Injury is something unique, he says the military can work on creating a unique treatment for it. 

Brett Litz, a psychologist with the VA Boston, says traditional PTSD treatments work pretty well to heal from the threat of losing one’s own life. But he says it’s less effective for Moral Injury.

“It does not sufficiently capture what is over the long haul going to be haunting and anguishing for service members from these long wars,” Litz says.

So they created something called Adaptive Disclosure Therapy. It’s relatively short, just six sessions. At one point, soldiers are asked to relive their most disturbing experiences, and to imagine they’re speaking to an unconditionally loving and non-judging person.

Early results from a pilot trial held with Marines at Camp Pendleton in California are encouraging, but Litz says the therapy only aims to plant a seed.

“We’re not healing people,” he says. “We’re just starting a healing process.”

Another problem with Moral Injury is that vets don’t really like to talk about it. Sergeant First Class  Johnson is now 34. He’s served three tours in Iraq, two in Afghanistan. He lives with moral injuries every day. And he only talks with a few people about the worst of what he’s seen and done – mostly guys who were there, because soldiers create a camaraderie tested under siege that Johnson says civilians can’t get.”

“I don’t think people can possibly understand. Like how much you give up, kind of like you keep going, you keep fighting. But, you know, it’s hard to explain,” Johnson says. “We joke about it a lot . We kind of make jokes of it that we’re not human anymore. Like the humanity is dead in us.”

Only a handful of people in the VA and the military are pushing to have the phrase Moral Injury officially used in diagnosing some forms of PTSD. But they’re making incremental progress. The Department of Defense is now conducting a clinical trial on Adaptive Disclosure Therapy. And they argue that the military will need the same kind of courage it takes to fight on the battlefield to find treatment for the kinds of deep psychological wounds veterans face today.

A version of this story aired that incorrectly referred to the type of therapy in its second mention.