Archive for Morality

Moral Injury in the Context of War (U.S. Dept. of VA)

Posted in Moral Injury with tags , , , , , , , on 4 December 2012 by Daryl Densford

Copied without edit for educational purposes from U.S. Department of Veterans Affairs, National Center for PTSD.


Shira Maguen, PhD and Brett Litz, PhD


What is moral injury?

Like psychological trauma, moral injury is a construct that describes extreme and unprecedented life experience including the harmful aftermath of exposure to such events. Events are considered morally injurious if they “transgress deeply held moral beliefs and expectations” (1). Thus, the key precondition for moral injury is an act of transgression, which shatters moral and ethical expectations that are rooted in religious or spiritual beliefs, or culture-based, organizational, and group-based rules about fairness, the value of life, and so forth.

Moral injury in war

In the context of war, moral injuries may stem from direct participation in acts of combat, such as killing or harming others, or indirect acts, such as witnessing death or dying, failing to prevent immoral acts of others, or giving or receiving orders that are perceived as gross moral violations (2). The act may have been carried out by an individual or a group, through a decision made individually or as a response to orders given by leaders.


  • Unintentional Errors: Military personnel are well trained in the rules of engagement and do a remarkable job making life or death decisions in war; however, sometimes unintentional error leads to the loss of life of non-combatants, setting the stage for moral injury.
  • Transgressive Acts of Others: Service members can be morally injured by the transgression of peers and leaders who betray expectations in egregious ways.

What is the aftermath of moral injury?

In terms of the aftermath of moral injuries, transgressive acts may result in highly aversive and haunting states of inner conflict and turmoil. Emotional responses may include:

  • shame, which stems from global self-attributions (e.g., “I am an evil terrible person; I am unforgivable”)
  • guilt
  • anxiety about possible consequences
  • anger about betrayal-based moral injuries

Behavioral manifestations of moral injury may include:

  • anomie (e.g., alienation, purposelessness, and/or social instability caused by a breakdown in standards and values)
  • withdrawal and self-condemnation
  • self-harming (e.g., suicidal ideation or attempts)
  • self-handicapping behaviors (e.g., alcohol or drug use, self-sabotaging relationships, etc.)

Additionally, moral injury has been posited to result in the re-experiencing, emotional numbing, and avoidance symptoms of PTSD. In addition to grave suffering, these manifestations of moral injury may lead to an array of anti-social behaviors, under- or unemployment, and failed or harmed relationships with loved ones and friends.

Does killing cause moral injury?

Several studies demonstrate an association between killing in war and mental and behavioral health problems, which may be proxies for moral injury (3-8).

For example:

  • Across eras (e.g., Vietnam, Gulf War, Operation Iraqi Freedom (OIF)) those who kill in war are at greater risk for a number of mental health consequences and functional difficulties, including PTSD, after accounting for a number of demographic variables and other indicators of combat exposure (3-5).
  • In returning OIF Veterans, even after controlling for combat exposure, taking another life was a significant predictor of PTSD symptoms, alcohol abuse, anger, and relationship problems (3).
  • Vietnam Veterans who reported killing were twice as likely to report suicidal ideation as those who did not, even after accounting for general combat exposure, PTSD and depression diagnoses (9). In OIF Veterans, the relationship between killing and suicidal ideation was mediated by PTSD and depression symptoms (10).

Although killing may be a precursor to moral injury, it is important to note that not all killing in war results in adverse outcomes for military personnel. As outlined in the section above, certain elements need to be present for moral injury to occur, including a perceived transgression that goes against individual of shared moral expectations.

For example, a military member who kills an enemy combatant in self-defense may perceive that the death was justified. If however, a civilian was perceived to be armed and consequently killed, with military personnel later discovering that the individual was in fact unarmed, this may set the stage for the development of moral injury.

Are moral injury and PTSD the same?

Although more research is needed to answer this question, at present, although the constructs of PTSD and moral injury overlap, each has unique components that make them separable consequences of war and other traumatic contexts.

  • PTSD is a mental disorder that requires a diagnosis. Moral injury is a dimensional problem – there is no threshold for the presence of moral injury, rather, at a given point in time, a Veteran may have none, or mild to extreme manifestations.
  • Transgression is not necessary for a PTSD diagnosis nor does the PTSD syndrome sufficiently capture moral injury (shame, self-handicapping, guilt, etc.).

Consequently, it is important to assess mental health symptoms and moral injury as separate manifestations of war trauma to form a comprehensive clinical picture, and provide the most relevant treatment.

What can be done to treat moral injury in Veterans of war?

Existing evidence-based treatments (EBTs) for PTSD supported by the VA, namely Prolonged Exposure Therapy (PE) and Cognitive Processing Therapy (CPT) may sufficiently address the moral wounds of war in service members and Veterans.

However, because these therapies do not explicitly consider the unique clinical issues that arise from combat losses and experiences that are morally compromising, and because extant EBTs were primarily developed to target posttraumatic conditioned fear memories and related beliefs among victims of trauma, they may not be sufficient for service members and Veterans who suffer from the moral injuries of war, especially killing-based transgressions.

Current research for treatment of moral injury

In service of broadening the discourse, we generated and are currently testing interventions that specifically target moral injury among Veterans of war.

The first intervention is a six-session module called Impact of Killing in War (IOK), developed to augment existing EBTs for PTSD (i.e., IOK is used in conjunction with existing EBT for PTSD interventions, in those who have conflict related to killing in war). ). Pilot testing is currently underway. IOK contains the following elements, presented within a cognitive-behavioral framework:

  • education about the complex interplay of the biopsychosocial aspects of killing in war that may cause inner conflict and moral injury
  • identification of meaning elements and cognitive attributions related to killing in war
  • self-forgiveness (which entails cognitive therapy and for some the promotion of spirituality or faith-based religious practices)
  • making amends tailored to the individual (this may include writing forgiveness letters and an action plan to start the process of making amends)

The second treatment is called Adaptive Disclosure (AD), an eight-session intervention that takes into account unique aspects of the phenomenology of military service in war in order to address difficulties such as moral injury and traumatic loss that are not explicitly addressed in extant EBTs (11). At its core, AD is an experiential exposure-based approach.

  • Exposure is used to uncover core features of focal combat and operational trauma and as a means of articulating the meaning and implication of these events.
  • If the focal combat event is fear and life-threat-based, exposure is the sole approach.
  • If the focal trauma is loss-based, patients are also asked to have an imaginary emotionally evocative real-time dialogue with the lost person.
  • For moral injury, patients are guided through a real-time dialogue with a forgiving and compassionate moral authority about the transgression.

The added experiential strategies are designed to expose patients to corrective information about the meaning and implication of their war experiences. In an open trial, 44 Marines received AD in garrison. Participating Marines demonstrated significant reductions in PTSD symptoms, depression symptoms, and negative posttraumatic appraisals; AD was also associated with increases in posttraumatic growth (12).


  1. Litz, B.T., Stein, N., Delaney, E., Lebowitz, L., Nash, W.P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695-706.
  2. Drescher, K., Foy, D., Kelly, C., Leshner, A., Schutz, A., & Litz, B.T. (2011). An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology, 17, 8-13.
  3. Maguen, S., Metzler, T.J., Litz, B.T., Seal, K.H., Knight, S.J., & Marmar, C.R. (2009). The impact of killing in war on mental health symptoms and related functioning. Journal of Traumatic Stress, 22, 435-443.
  4. Maguen, S., Lucenko, B.A., Reger, M.A., Gahm, G.A., Litz, B.T., Seal, K.H., Knight, S.J., & Marmar, C.R. (2010). The impact of reported direct and indirect killing on mental health symptoms in Iraq War veterans. Journal of Traumatic Stress, 23, 86-90.
  5. Maguen, S., Vogt, D.S., King, L.A., King, D.W., Litz, B.T., Knight, S.J., & Marmar, C.R. (2010, October 4).The impact of killing on mental health symptoms in Gulf War veterans. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. doi: 10.1037/a0019897.
  6. Fontana, A., Rosenheck, R. & Brett, E. (1992). War zone traumas and posttraumatic stress disorder symptomatology. Journal of Nervous and Mental Disease, 180, 748-755.
  7. MacNair, R.M. (2002). Perpetration-inducted traumatic stress in combat veterans.Peace and Conflict: Journal of Peace Psychology, 8, 63-72.
  8. Fontana, A. & Rosenheck, R. (1999). A model of war zone stressors and posttraumatic stress disorder. Journal of Traumatic Stress, 12, 111-26.
  9. Maguen, S., Metzler, T.J., Bosch, J., Marmar, C.R., Knight, S.J., & Neylan, T.C. Killing in combat is an independent predictor of suicidal ideation. Manuscript under review.
  10. Maguen, S., Luxton, D.D., Skopp, N.A., Gahm, G.A., Reger, M.A., Metzler, T.J., & Marmar, C.R. (2011). Killing in combat, mental health symptoms, and suicidal ideation in Iraq War Veterans. Journal of Anxiety Disorders, 25, 563-567.
  11. Steenkamp, M., Litz, B. T., Gray, M., Lebowitz, L., Nash, W., Conoscenti, L., Amidon, A., & Lang, A., (2011). A brief exposure-based intervention for service members with PTSD. Cognitive and Behavioral Practice, 18, 98-107.
  12. Gray, M.J., Schorr, Y., Nash, W., Lebowitz, L., Amidon, A., Lansiung, A. Maglione, M., Lang, A.J., Litz, B.T. (in press). Adaptive Disclosure: An open trial of a novel exposure-based intervention for service members with combat-related psychological stress injuries. Behavior Therapy.
Date Created: 12/23/2011 See last Reviewed/Updated 04/20/2012
Copied without edit for educational purposes from U.S. Department of Veterans Affairs, National Center for PTSD.

“Moral Injury” and Modern War (The American Conservative)

Posted in Moral Injury with tags , , , , , , , on 4 December 2012 by Daryl Densford

This article is copied without edit for educational purposes from The American Conservative.

The psychological wounds of PTSD are now recognized —but what about the ethical wounds of training to kill?

(Via  By NAN LEVINSON • June 28, 2012

“PTSD is going to color everything you write,” came the warning from a stepmother of a Marine, a woman who keeps track of such things.  That was in 2005, when post-traumatic stress disorder, a.k.a. PTSD, wasn’t getting much attention, but soon it was pretty much all anyone wrote about.  Story upon story about the damage done to our guys in uniform — drinking, divorce, depression, destitution — a laundry list of miseries and victimhood. When it comes to veterans, it seems like the only response we can imagine is to feel sorry for them.Victim is one of the two roles we allow our soldiers and veterans (the other is, of course, hero), but most don’t have PTSD, and this isn’t one of those stories.

Civilian to the core, I’ve escaped any firsthand experience of war, but I’ve spent the past seven years talking with current GIs and recent veterans, and among the many things they’ve taught me is that nobody gets out of war unmarked.  That’s especially true when your war turns out to be a shadowy, relentless occupation of a distant land, which requires you to do things that you regret and that continue to haunt you.

Theoretically, whole countries go to war, not just their soldiers, but not this time.  Civilian sympathy for “the troops” may be just one more way for us to avoid a real reckoning with our last decade-plus of war, when the hostilities in Iraq and Afghanistan have shown up on the average American’s radar only if somebody screws up or noticeable numbers of Americans get killed.  The veterans at the heart of this story — victims, heroes, it doesn’t matter — struggle to reconcile what they did in those countries with the “service” we keep thanking them for.  We can see them as sick, with all the stigma, neediness, and expense that entails, or we can recognize them as human beings, confronting the morality of what they’ve done in our name and what they’ve seen and come to know — even as they try to move on.

Sacred Wounds, Moral Injuries

Former Army staff sergeant Andy Sapp spent a year at Forward Operating Base Speicher near Tikrit, Iraq, and has lived for the past six years with PTSD.  Seven if you count the year he refused to admit that he had it because he never left the base or fired his weapon, and who was he to suffer when others had it so much worse?  Nearly 50 when he deployed, he was much older than most of his National Guard unit.  He had put in 17 years in various branches of the military, had a stable family, strong religious ties, a good education, and a satisfying career as a high-school English teacher.  He expected all that to insulate him, so it took a while to realize that the whole time he was in Iraq, he was numb.  In the end, he would be diagnosed with PTSD and given an 80% disability rating, which, among other benefits, entitles him to sessions with a Veterans Administration psychologist, whom he credits with saving his life.

Andy recalls a 1985 BBC series called “Soldiers” in which a Marine commander says, “It’s not that we can’t take a man who’s 45 years old and turn him into a good soldier. It’s that we can’t make him love it.”  Like many soldiers, Andy had assumed that his role would be to protect his country when it was threatened. Instead, he now considers himself part of “something evil.” So at a point when his therapy stalled and his therapist suggested that his spiritual pain was exacerbating his psychological pain, it suddenly clicked. The spiritual part he now calls his sacred wound. Others call it “moral injury.”

It’s a concept in progress, defined as the result of taking part in or witnessing something of consequence that you find wrong, something which violates your deeply held beliefs about yourself and your role in the world. For a moment, at least, you become what you never wanted to be. While the symptoms and causes may overlap with PTSD, moral injury arises from what you did or failed to do, rather than from what was done to you.  It’s a sickness of the heart more than the head. Or, possibly, moral injury is what comes first and, if left unattended, can congeal into PTSD.

What we now call PTSD goes way back.  In Odysseus in America, psychiatrist (and MacArthur “genius” grantee) Jonathan Shay has traced similar symptoms to Homer’s account of Odysseus’s homecoming from the Trojan War.  The idea that a soldier may continue to be haunted by his wartime life has had a name since at least the Civil War.  It was called “soldier’s heart” then, a lovely name for a terrible affliction.

In World War I, it went by the names “shell shock” and “war neurosis” and was so widespread that Britain devoted 19 hospitals solely to treating soldiers who suffered from it.  During WWII, it was called “battle fatigue,” “combat neurosis,” or “gross stress reaction,” and the problem was severe enough in the U.S. Army that, at one point, psychiatric discharges outpaced new recruits. The Vietnam War gave us the term “post-Vietnam syndrome,” which in time evolved into PTSD, and eventually the insight that, whatever its name, it is probably neurologically based.

PTSD’s status as an anxiety disorder — and as the only mental health condition officially defined as caused by a single, external event — was established in 1980, when it was enshrined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the bible of psychiatry. The diagnostic criteria have expanded since then and will probably be altered again in next year’s version of the DSM.  That troubles many therapists treating the ailment; some don’t think PTSD is a disease, others argue that the symptoms are just a natural response to being at war or that, in labeling it a disorder, political and cultural norms are being invoked to reinforce what is considered orderly.  As Katherine Boone, writing in the Wilson Quarterly, put it, “If you react normally to trauma, you have a disorder; if you act abnormally, you don’t.”

Most PTSD is short term, but perhaps one-third of cases become chronic, and those are the ones we keep hearing about, in part because it costs a lot to treat them.  For a variety of reasons, no one seems to have an exact number of recent combat veterans with PTSD.  The Veterans Administration estimates that between 11% and 20% of the 2.3 million troops who have cycled through Iraq and Afghanistan suffer from it, and the Congressional Budget Office calculates a cost of $8,300 per patient for the first year of treatment.  Do the math, and you could be talking about as much as $3.8 billion a year.  (What we’re not talking about nearly enough is the best way to prevent PTSD and other war-caused psychic distress, which is not to put soldiers in such untenable situations in the first place.)

Since the early days of diagnosis — when you were either sick with PTSD or you were fine — the medical response to it has gained in nuance and depth, which has brought beneficial funding for research and treatment.  In the public mind, though, PTSD still scoops up everything from risky behavior and aggression to substance abuse and suicide — kind of the way “Alzheimer’s” as a catch-all label stands in for forgetfulness over 50 — and that does a disservice to veterans who aren’t sick, but aren’t fine either.

“What you come into the war with will dictate how you come out of war,” Joshua Casteel testified about a soldier’s conscience at the Truth Commission on Conscience and War, which convened in New York in March 2010.  He had spent five months as an interrogator at Abu Ghraib shortly after the prisoner abuse scandal broke there.  He later left the Army as a conscientious objector after an impassioned conversation about faith and duty with a young Saudi jihadist, whom he was supposed to be questioning, led him to conclude that he could no longer do his job. Casting a soldier’s experience as unfathomable to anyone else was not only inaccurate, but also damaging, he said; he had never felt lonelier than when people were afraid to ask about his life during the war.

Our warriors today are all volunteers who signed up and are apparently supposed to put up with whatever comes their way.  As professionals, they’re supposed to be ready to fight, but as counterinsurgents they’re supposed to be tender-hearted and understanding — at least to kids, those village elders they’re fated to drink endless cross-cultural cups of tea with, and their buddies.  (Every veteran has a kid story, and mourning lost friends with tattoos, rituals, and drunken sorrow are among the few ways they’re allowed to grieve publicly.) They’re supposed to be anguished when they hear about the “bad apples” who gang-raped, then murdered and set fire to a 15-year-old girl near Mahmoudiya, Iraq, or the “kill team” that hunted Afghan civilians “for sport.”

Maybe it’s the confusion of these mixed signals that makes us treat our soldiers as if they’re tainted by some special, unwanted knowledge, something that should drive them over the edge with grief and guilt and remorse.  Maybe we think our soldiers are supposed to suffer.

The Right to Miss

A couple of decades ago, Dave Grossman, a professor of psychology and former Army Ranger, wrote an eye-opening, bone-chilling book called On Killing.  It begins with the premise that people have an inherent resistance to killing other people and goes on to examine how the military overcomes that inhibition.

On Killing examines the concerted effort of the military to increase firing rates among frontline riflemen.  Reportedly only about 15%-20% of them pulled the trigger during World War II.  Grossman suggests that many who did fire “exercised the soldier’s right to miss.”  Displeased, the U.S. Army set out to redesign its combat training to make firing your weapon a more reflexive action. The military (and most police forces) switched to realistic, human-shaped silhouettes, which pop up and fall down when hit, and later added video simulators for the most recent generation of soldiers raised on virtual reality.

This kind of Skinnerian conditioning — Grossman calls it “modern battleproofing” — upped the firing rate steadily to 55% in Korea, 90% in Vietnam, and somewhere near 100% in Iraq.  Soldiers are trained to shoot first and evaluate later, but as Grossman observes, “Killing comes with a price, and societies must learn that their soldiers will have to spend the rest of their lives living with what they have done.”

That price could be called moral injury.

The term may have come from Jonathan Shay, though he demurs.  Whatever its origin, it wasn’t until the end of 2009 that it began to resonate in therapeutic communities. That was when Brett Litz, the Associate Director of the National Center for PTSD in Boston, and several colleagues involved in a pilot study for the Marines published “Moral injury and moral repair in war veterans,” a paper aimed at other clinicians.  Their stated aim was not to create a new diagnostic category, nor to pathologize moral discomfort, but to encourage discussion and research into the lingering effects on soldiers of their moral transgressions in war.

The authors found that emotional distress was caused less by fear of personal harm than by the dissonance between what soldiers had done or seen and what they had previously held to be right.  This echoes Grossman, who concludes that the greatest cause of psychological injury to soldiers is the realization that there are people out there who really want to hurt you.

Moral injury seems to be widespread, but the concept is something of an orphan.  If it’s an injury, then it needs treatment, which puts it in the realm of medicine, but its overtones of sin and redemption also place it in the realm of the spiritual and so, religion.  Chaplains, however, are no better trained to deal with it than clinicians, since their essential job is to patch up soldiers, albeit spiritually, to fight another day.

Yet the idea that many soldiers suffer from a kind of heartsickness is gaining traction.  The military began to consider moral injury as a war wound and possible forerunner of PTSD when Litz presented his research at the Navy’s Combat Operational Stress Control conference in 2010.  The American Psychiatric Association is also thinking about adding guilt and shame to its diagnostic criteria for PTSD.  A small preliminary survey of chaplains, mental health clinicians, and researchers found unanimous support for including some version of moral injury in the description of the consequences of war, though they weren’t all enamored of the term.  As if to mark the start of a new era in considering the true costs of war, a new institution, the Soul Repair Center, has just been launched at Brite Divinity School in Fort Worth, Texas, with a $650,000 grant from the Lilly Foundation to conduct research and education about moral injury in combat veterans.

Of course, to have a moral injury, you have to have a moral code, and to have a moral code, you have to believe, on some level, that the world is a place where justice will ultimately prevail.  Faith in a rightly ordered world must be hard for anyone who has been through war; it’s particularly elusive for soldiers mired in a war that makes little sense to them, one they’ve come, actively or passively, to resent and oppose.

When your job requires you to pull sleeping families from their beds at midnight thousands of miles from your home, or to shoot at oncoming cars without knowing who’s driving them, or to refuse medical care to decrepit old men, you begin to question what doing your job means.  When the reasons keep shifting for what you’re supposed to be doing in a country where most of the population wants you to go home even more than you want to, it’s hard to maintain any sense of innocence.  When someone going about his daily life is regularly mistaken for someone who means to kill you — as has repetitively been the case in our occupations of both Iraq and Afghanistan — everyone becomes the enemy.  And when you try — and fail — to do the right thing in a chaotic and threatening situation, which nothing could have trained you for, the enemy can move inside you and stay there for a very long time.

In trying to heal from a moral injury, people struggle to restore a sense of themselves as decent human beings, but the stumbling block for many veterans of recent U.S. wars is that their judgment about the immorality of their actions may well be correct.  Obviously, suffering which can be avoided should be, but it’s not clear what’s gained by robbing soldiers of a moral compass, save a salve to civilian conscience.  And despite all the gauzy glory we swath soldiers in when we wave them off to battle, nations need their veterans to remember how horrible war is, if only to remind us not to launch them as heedlessly as the U.S. has done over these last years.

When you’ve done irreparable harm, feeling bad about your acts — haunted, sorrowful, distraught, diminished, unhinged by them — is human.  Taking responsibility for them, however, is a step toward maturity.  Maybe that’s the way the Army makes a man of you, after all.

Two final observations from veterans who went to war, then committed themselves to waging peace, apparently a much harder task: Dave Cline began his lifetime of antiwar work as a G.I. in the Vietnam War.  A few years into the Iraq War, when he was president of Veterans For Peace, he told me, “Returning soldiers always try to make it not a waste.”  The second observation comes from Drew Cameron in a preface to a book of poems by a fellow veteran, published by his Combat Paper Press: “To know war, to understand conflict, to respond to it is not an individual act, nor one of courage.  It is rather a very fair and necessary thing.”

Recognizing moral injury isn’t a panacea, but it opens up multiple possibilities.  It offers veterans a way to understand themselves, not as mad or bad, but as justifiably sad, and it allows the rest of us a way to avoid reducing their wartime experiences to a sickness or a smiley face.  Most important, moral repair is linked to moral restitution.  In an effort to waste neither their past nor their future, many veterans work to help heal their fellow veterans or the civilians in the countries they once occupied.  Others work for peace so the next generations of soldiers won’t have to know the heartache of moral injury.

Nan Levinson, a Boston-based journalist, reports on civil liberties, politics, and culture. Her next book, War Is Not a Game, is about the recent G.I. antiwar movement.Copyright 2012 Nan Levinson.  Photo credit:  Jared Rodriguez / (CC BY-NC-SA 2.0)


This article is copied without edit for educational purposes from The American Conservative.


A New Theory of PTSD and Veterans: Moral Injury (The Daily Beast)

Posted in Moral Injury with tags , , , , , , on 19 October 2012 by Daryl Densford

This article, which explores “moral injury” as a contributing factor to PTSD, is copied without editing for educational purposes from The Daily Beast.

Soldiers are supposed to be tough, cool, and ethically confident. But what happens when they have seen and done things that haunt their consciences? New studies suggest that the pain of guilt may be a key factor in the rise of PTSD.

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.

Tony Dokoupil joins “Jarhead” author Anthony Swofford to talk about the changing definition of PTSD.

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.”

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

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


©2011 The Newsweek/Daily Beast Company LLC.  Article copied without edit for educational purposes from The Daily Beast