For US veterans, what does it mean to heal a moral injury?
| Concord, Calif.
War shaped Ryan Berg. He wishes some days he had chosen another path. He wishes every day his friend Gino had lived.
The intensity of two combat tours in Iraq cast Mr. Berg adrift within himself after his discharge in 2007. He fought against the feral memories of war. He sprayed anger at family, friends, strangers.
Why We Wrote This
That veterans can return from war with invisible wounds that need healing is now widely known. But moral injury, sometimes described as a “wound to the soul,” remains the least diagnosed and understood.
He sought escape from himself in drinking and drugs.
As returning troops readapt to the ethical dimensions of civilian life, the rationale for their behavior in war can appear indefensible in hindsight, clashing with long-held personal beliefs and perceptions of their own humanity. The lack of a peaceful resolution in Iraq and Afghanistan can intensify that self-reproach as they second-guess their faith in the military and the mission.
The unintended effects of America’s “forever wars” include a dawning awareness among clinicians about what they call moral injury.
Treatment for post-traumatic stress disorder attempts to alleviate fear and repair the mind. Therapy for moral injury seeks to ease guilt and mend the spirit. Research showing a potential link between moral injury and a higher risk of suicide among active-duty troops illuminates the perils of providers missing signs of the condition.
Mr. Berg revived his spirit by degrees. He learned to look ahead when stray thoughts wrenched him into the past. Instead of retreating inward, he looks to help other veterans of the forever wars. He knows some remain trapped on an unseen battlefield. He seeks to bring them back.
“It’s been hard for me to feel proud of what I did in Iraq,” he says. “I don’t want them going through that. I don’t want them to feel alone.”
The Marine Corps observes its birthday every Nov. 10. On that day in 2004, as the Corps turned 229, Peter Giannopoulos spotted his friend Ryan Berg inside a mess tent on a U.S. military base in central Iraq.
Both men had deployed weeks earlier with the Marine Corps Reserve to an area known as the Triangle of Death. By then, less than two years after American forces had invaded, bloodshed and chaos engulfed the country as the Iraqi insurgency burned to full flame.
The two corporals smiled at the chance meeting, their first in the war zone. “Happy birthday, Marines,” Giannopoulos said to Berg and a few others seated by him. Berg chatted with him for a minute before Gino, as most called him, strode outside to join his platoon for its next mission.
Why We Wrote This
That veterans can return from war with invisible wounds that need healing is now widely known. But moral injury, sometimes described as a “wound to the soul,” remains the least diagnosed and understood.
The following day, after returning to base from a patrol, Berg stood talking with his squad leader. Another Marine from Giannopoulos’ unit rushed toward them. Distress choked his voice. “It’s Gino! It’s Gino!” he said.
Insurgents had attacked their platoon. Gino was 22. He died on Veterans Day.
The loss of Corporal Giannopoulos on a distant battlefield 15 years ago lies at the heart of Mr. Berg’s complex emotions about the Iraq War.
“When you’re there, everything has extreme significance. It all really matters in the moment,” he says. The demands of combat left little time to ponder the reasons for the U.S. military’s broader mission or to grieve for Gino. “You’re trying to survive. That’s it.”
The passage of years has brought the fog of war into focus for Mr. Berg, who deployed again to the country in 2006 and whose doubts about the conflict’s purpose have sharpened. He regards the ongoing turmoil in Iraq, where security forces in Baghdad killed more than 100 people during anti-government protests last month, as a repudiation of the U.S. war effort.
“What did we come away with? Did we really influence the country and make it a better place?” asks Mr. Berg, who lives in Concord, California, northeast of San Francisco. He mentions the deaths of almost 4,600 U.S. troops and tens of thousands of Iraqi civilians since the invasion in 2003. “I do feel let down. There wasn’t much of a plan to create order after we got there, and a lot of people have been killed. It’s really hard to say it was worth it.”
His perspective aligns with the majority of veterans who deployed to Iraq and Afghanistan as revealed by a poll earlier this year from the Pew Research Center. The survey found that most of the men and women sent to fight the longest wars in U.S. history now question whether the cause justified the risks they endured and the lives that were sacrificed.
The violence that persists in both countries – the latest peace talks between U.S. and Afghan Taliban officials collapsed in September – magnifies war’s personal toll for many veterans. Their pride in once wearing the uniform collides with a feeling of futility about what their service achieved and a belief that military leaders failed or deceived them and their fallen comrades. The sense of violation can contribute to a lingering crisis of the conscience and spirit – a concept that behavioral health providers call moral injury.
“After nearly two decades of these wars, there has been less clarity about the purpose and the value of fighting them,” Dr. Shauna Springer says. A psychologist in the San Francisco Bay Area, she has counseled hundreds of Iraq and Afghanistan war veterans coping with combat trauma. “For some service members, the question of what they were really doing can become harder to answer.”
For Mr. Berg, the hazy intent of the Iraq War compounds the piercing absence of his friend. “Did Gino losing his life there matter? I don’t know,” he says. “We were expendable – that’s how it felt.”
The toll of moral injury
The unintended effects of America’s “forever wars” include a dawning awareness among clinicians about moral injury. Endless conflict has wrought greater insight into the unending anguish that combat can impose on troops.
Researchers describe moral injury as a breach of a person’s ethical code that inflicts lasting behavioral, emotional, and psychological damage. This “wound to the soul” most often occurs when individuals commit, fail to prevent, or witness an act that cuts against their moral beliefs. The experience burdens them with acute guilt and shame that at once distorts their self-identity and provokes reflexive distrust of others.
“It’s something that obliterates your expectation of life as you understand it,” says Dr. Brett Litz, a psychologist with the Veterans Affairs system in Boston and a leading researcher into moral injury. “It reflects a profound and intense and debilitating experience that changes how you see yourself and the world around you.”
In the context of troops at war, moral injury arises from diverse causes: killing an enemy combatant or civilian; giving an order that results in the injury or death of another service member; failing to save the life of a comrade; witnessing the death of civilians.
A moment from Anthony Anderson’s first tour in Iraq in 2004 still shadows him. Rockets and mortars fired by insurgents had wounded civilians outside the perimeter of his unit’s base. His platoon later rolled out in a convoy for the day’s mission, and beyond his truck’s windows, he saw bodies splayed on the ground.
His eyes met the agonized gaze of a man whose white shalwar kameez had turned crimson from a stomach wound. Mr. Anderson asked over the radio if the troops could stop to provide medical aid. The order came back to keep moving.
His shame over what he perceived as a betrayal of the Iraqi people has never waned. In the wounded man’s stare, he glimpsed a nation’s misery, a covenant broken – an entire war gone wrong.
“Do I think getting rid of Saddam Hussein was something worth doing? Yes,” says Mr. Anderson, who works for a legal services company in Houston. “But you can’t point to any part of life – in America or Iraq – that’s better because we invaded.”
His second combat tour in 2007 further battered his conscience. Six years later, he joined a fellow Iraq War veteran on a 2,700-mile hike from their native Wisconsin to the California coast. The duo traversed the contours of their guilt and grief in a journey captured in the documentary “Almost Sunrise” that sought to draw attention to moral injury.
During the five-month trek, Mr. Anderson began to resurface from his desolation, and he since has reclaimed his self-worth through fatherhood and serving as a veteran peer counselor. Yet his memories of war are embalmed in remorse.
“Even though I was proud to have served, I felt like a fraud,” he says. “I feel guilty because I contributed to the problems the Iraqi people continue to have today.”
A deepening regret
Psychiatrist and author Jonathan Shay introduced the idea of moral injury through his work with Vietnam War veterans in the 1980s and ’90s. More than a quarter-century later, the concept remains unrecognized as a formal diagnosis, less studied and understood by mental health providers than the clinical condition of post-traumatic stress disorder.
PTSD refers to a mental and biological reaction that recurs for months and sometimes years after an individual endures or witnesses a traumatic event or series of events. The anxiety and fear that linger can induce abrupt mood swings, avoidance of public settings, and withdrawal from family and friends. Combat veterans diagnosed with the disorder also tend to exhibit hypervigilance, a state of extreme alertness that carries over from the war zone.
In treating veterans of America’s 21st-century wars, Dr. Litz and a coterie of clinicians have expanded research into moral injury, framing the condition as related to yet distinct from PTSD.
Their studies identify guilt as a crucial factor that distinguishes moral injury, even as other symptoms – anxiety and despair, flashbacks and nightmares, social isolation and suicidal thoughts – overlap with PTSD. The findings suggest that guilt and shame typically emerge over months or years as combat veterans gain perspective on a morally injurious act or event.
As returning troops readapt to the ethical dimensions of civilian life, the rationale for their behavior in war can appear indefensible in hindsight, clashing with long-held personal beliefs and perceptions of their own humanity. The lack of a peaceful resolution in Iraq and Afghanistan can intensify that self-reproach as they second-guess their faith in the military and the mission.
“If they feel the sacrifice has a degree of nobility and the war has the right outcome, it moderates the damage done psychologically,” Dr. Litz says. Without sustained stability in either country, “there will be some who say, ‘I feel like a sucker.’”
Former Army Sgt. Nate Vass deployed to Afghanistan in 2006 convinced he had entered a just war. His view of the U.S. occupation, then in its fifth year, changed over the ensuing 16 months as he learned about the Afghan people and culture. He remembers wondering, “Why are we trying to westernize a country that really does not want to be westernized?”
Soon after his tour, Mr. Vass left the Army and returned home to California, disillusioned with the military and himself. He drank to submerge his anxiety and anger. He grew more detached, his days bereft of meaning, his nights suffused with dread.
VA clinicians diagnosed him with PTSD, and since moving to northern Montana two years ago, he has found solace in the serenity of the Rocky Mountains. His therapy takes the form of hiking and skiing, yet as his mind has calmed, his service in a war he deems misguided weighs on his spirit, a millstone heavier than any military medal.
“I feel a sense of bitterness about all of it,” Mr. Vass says of a conflict that has killed nearly 2,300 U.S. troops and passed the 18-year mark last month. “Not so much about what I had to deal with. But I have friends who came back and committed suicide and other guys who were killed on deployments. For what?”
U.S. military and civilian forces in Afghanistan expanded access to education for girls, strengthened voting rights, and trained and equipped Afghan security forces. Mr. Vass lists those examples as evidence that America’s intervention held potential to benefit the country – before adding that much of the progress has stalled and soon could vanish as the Taliban reasserts its influence.
He hears about the strife in Afghanistan and Iraq from friends in the military who have deployed in recent years. His regret deepens as the unrest passes almost without comment in America.
“We mourn our soldiers who die there. But we don’t mourn Afghan and Iraqi civilians – the tens of thousands, hundreds of thousands of civilians – who have been killed. What about them and their families? What do we owe them?”
Mending the spirit
Dr. Litz and his colleagues developed a treatment regimen for moral injury a decade ago called adaptive disclosure. One phase of the eight-week program involves a clinician guiding a veteran through a conversation with an imaginary and benevolent “moral authority” to talk about the act or event that has caused suffering. The patient then describes the regret and sorrow that has followed, and asks for forgiveness or a chance to atone.
“It’s akin to secular confession,” Dr. Litz says. “It’s to help the person divulge and unearth memories and details so those emotions can be felt and explored.”
An estimated 11% to 20% of the 2.7 million men and women who deployed to Iraq and Afghanistan have received a diagnosis of PTSD linked to their service. The percentage of former service members coping with moral injury appears comparable. A study last year showed that 9 in 10 veterans diagnosed with PTSD also exhibited at least one symptom associated with moral injury.
But with the VA’s prevailing emphasis on PTSD as a mental health diagnosis for combat veterans, the authors of another recent report warn that moral injury “can often go unrecognized and ignored” by clinicians.
Treatment for PTSD attempts to alleviate fear and repair the mind. Therapy for moral injury seeks to ease guilt and mend the spirit. Research showing a potential link between moral injury and a higher risk of suicide among active-duty troops illuminates the perils of providers missing signs of the condition.
“There’s an incredible urgency and need to elevate awareness around moral injury,” says Dr. Springer, who has treated veterans for the past decade, first within the VA system and now in private practice. She points out that most people diagnosed with PTSD either recover from or learn to manage their symptoms. “We have to make people familiar with moral injury in the way we’ve done with post-traumatic stress.”
Noel Lipana survived a therapy gauntlet in his journey toward recovery from moral injury. In 2008, he returned from Afghanistan without truly coming home. An Air Force major at the time, he trained U.S. troops how to detect and disable improvised explosive devices planted by insurgents.
He worked with two Army soldiers who died in separate explosions during his deployment. Mr. Lipana blamed himself for their deaths and those of four Afghan children killed in another blast.
He received a diagnosis of PTSD a few years after his discharge as he struggled with anger, flashbacks, and insomnia. VA clinicians in California prescribed medication and enrolled him in successive programs of long-term therapy. Nothing assuaged his guilt. His outlook darkened.
“Obviously, I forfeit my membership card to humanity,” he recalls thinking. “I don’t deserve to be healed.”
His spiral stopped with the aid of a pair of clinicians in Sacramento who run a group therapy program for veterans beset by moral injury. The sessions enabled Mr. Lipana to excavate his unresolved guilt and grief as he and his fellow veterans discussed the scalding emotional extremes of war, its random cruelties.
As part of the program, he wrote letters to the two soldiers and four kids who died to request their forgiveness. The process allowed him to remember, to mourn – and, in time, to heal.
“The fact is, no one’s moral architecture can withstand the exigencies of combat,” says Mr. Lipana, who previously helped run the Center for Post-Traumatic Growth in Sacramento, along with co-founders Melinda Keenan and Laura Williams, to promote recovery from psychological wounds. He has mined his ordeal to create a performance art piece titled “Quiet Summons” that translates the internal torment of moral injury through music, dance, and storytelling. He wants to offer hope to veterans edging toward the void.
“The basic message is, ‘It’s OK if you’re a little jacked-up, a little broken. We all are.’”
Searching for closure
Bobby Ehrig deployed with the Army to Bosnia-Herzegovina and neighboring Croatia as part of a peacekeeping mission in 1998. The region’s recent war had hollowed out cities, villages, and everyday life.
A couple of years ago, a friend of Mr. Ehrig’s visited Bosnia and sent him photos of areas where his unit had patrolled. The images elicited a stunned smile. He saw cities reborn and landscapes restored. The scars of violence had faded.
“That gave me a sense of elation,” he says. “I was like, ‘Wow, the sacrifice we made did something. We made a positive difference.’”
A veterans advocate in Albuquerque, New Mexico, Mr. Ehrig deployed twice to Iraq. A bomb blast in 2006 caused third-degree burns over 40% of his body, cutting short his second tour and military career. He seldom tracks news about the country but realizes the odds for peace are long. “There’s no sense of closure,” he says.
Mr. Ehrig avoids dwelling on whether the Iraq and Afghanistan wars were worth fighting. “That doesn’t help anything,” he says. Yet the ongoing upheaval in both countries can exacerbate the moral injury of veterans who consider the conflicts a betrayal, who believe they were duped, then discarded.
Kristofer Goldsmith deployed to Iraq in 2004 at age 19. Before flying over, he recalls his Army commanders referring to the unit’s role as that of a “cleanup crew,” as if the war would end any day. Driving from Kuwait to Baghdad with his platoon, he noticed troops replacing tents with semi-permanent structures at bases along the route.
“I knew we’d been lied to,” he says.
Mr. Goldsmith’s job required him to photograph mass graves, civilian casualties, and other grim scenes of war. The work preyed on his mind, and rather than deploy again in 2007, he attempted suicide. Army officials charged him with misconduct and kicked him out of the service.
“I don’t feel like my year in Iraq was worth anything. But I’ve still been dealing with the effects of it for most of my life,” says Mr. Goldsmith, who after leaving the military launched High Ground Veterans Advocacy, a nonprofit group in New York. He suggests that only a lasting peace could begin to redress the war’s costs in troop deaths, civilian casualties, and veteran suicides.
“If Iraq were a place I could return to as a tourist – and every veteran could return to – I think that would do a world of good and would help a lot of veterans heal,” he says. “Because now it’s like, ‘Does anybody remember what the mission was?’”
A devotion to fellow veterans
War shaped Ryan Berg. He wishes some days he had chosen another path. He wishes every day his friend Gino had lived.
The intensity of two combat tours in Iraq cast Mr. Berg adrift within himself after his discharge in 2007. He fought against the feral memories of war, the specter of death close at hand. He sprayed anger at family, friends, strangers. He sought escape from himself in drinking and drugs.
Mr. Berg revived his spirit by degrees. He finished college and graduate school. He co-founded a veterans support organization and began hosting a TV program about former service members. He learned to look ahead when stray thoughts wrenched him into the past.
Each time he fills up his car, the smell of gas reminds him of Iraq, where the oilfields burned and his friend perished. The question arrives unbidden. “How did Gino losing his life in Iraq make sense?”
Mr. Berg answers with his devotion to veterans of the forever wars. He knows some remain trapped on an unseen battlefield. He seeks to bring them back.
“It’s been hard for me to feel proud of what I did in Iraq,” he says. “I don’t want them going through that. I don’t want them to feel alone.”
