Feature Article

Contest winner: Moral injury as a new normal in the modern wars

When combatants commit acts that transgress their moral beliefs or witness others doing so, they experience moral conflict.

By Jeremy Jinkerson

Orders are given, you act, and your sense of what's right is betrayed (Guntzel et al., 2013, p. 7).

Many of combat's common effects can be explained by the physiological stress response (e.g., elevated heart rate, adrenaline dump) and emotional reactions (e.g., fear of death/injury). For most people, however, combat is more than a physiological and psychological experience. The intense killing that modern combat requires activates moral schemas, making combat a spiritual encounter (Grossman, 2009; Marlantes, 2012; Nakashima Brock & Lettini, 2013; Shay, 2003). Distinct from possible physical and psychological trauma, witnessing and/or participating in violence can injure one's moral core, resulting in spiritual crisis and intense shame (Grossman, 2009; Litz et al., 2009). Modern training and combat conditions have made this moral injury increasingly likely, so moral conflict may now be considered a normal response to war.

When combatants commit acts that transgress their deeply held moral beliefs or witness others doing so, they experience moral conflict. Cognitive dissonance is created between reality, moral values, and beliefs about personal goodness (Drescher et al., 2011). Such events include killing, within-ranks violence, and betrayals. The events most likely to cause moral injury are failing to help people in pain, witnessing atrocities (i.e., cities and people burning), and killing civilians (Drescher et al., 2011; Litz et al., 2009; Nash & Litz, 2013; Vargas, Hanson, Kraus, Drescher, & Foy , 2013). Because modern wars have involved guerrilla tactics, city warfare, and nonuniformed enemy forces, receiving orders to kill potentially neutral targets has become increasingly common. For example, U.S. military combatants in Afghanistan have been ordered to shoot nonuniformed families who entered unauthorized areas.

Just as events that may cause moral injury have been identified, predictable responses have also been proposed and partially validated. After a moral injury, veterans hold old beliefs and new beliefs that are contradictory (i.e., cognitive dissonance), such as “We only kill the enemy” and “That person was a civilian.” This moral conflict is hypothesized to lead to shame, guilt, anxiety, and self-condemnation (Litz et al., 2009). Following self-condemnation, moral injury can lead to familiar posttraumatic stress disorder (PTSD) symptoms, including anger, depression, and self-harm (Buechner, 2014). Unlike PTSD, however, moral injury is associated with self-handicapping and self-harm, which are inflicted as punishment for the moral transgression (Shay, 2003). Through content analysis of responses from the National Vietnam Veterans' Readjustment Study, Vargas et al. (2013) found that 33 of 200 randomly sampled theater veterans had experienced potentially morally injurious events. Their responses to questions about how the Vietnam War had affected their lives included the expected moral injury themes of loss of trust, spiritual/existential issues, self-depreciation, social problems, and psychological problems. The most salient themes were loss of trust in others and spiritual/existential issues, including negative attributions about God. Among these individuals, veterans with themes of civilian deaths or disproportionate violence reported the most symptoms, making these types of moral injury both the most frequent and the deepest.

Overcoming the Aversion to Kill

War historians investigating pre-Vietnam wars found something strange: Many soldiers did not fire their weapons (Grossman, 2009; Kraus, 2014). For instance, numerous Civil War muzzleloaders have been discovered that were double-loaded up to four times, indicating that soldiers incorrectly reloaded their weapons rather than shoot at the enemy. Although his controversial reports lacked modern statistical methods (Aveni, n.d.), Marshall (1947/2000) asserted that less than 25 percent of American soldiers fired their weapons in World War II, and in the Korean War, the number had only risen to approximately 50 percent. There are multiple explanations for low fire rates, including fear, lack of experience, and having no target (Aveni, n.d.). Another explanation is that man is instinctually averse to killing. Having the ability to think about killing another human before doing so provides an opportunity for decision. Perhaps this a priori moment of moral conflict is why muzzleloaders were serially reloaded. Perhaps it is why the firing rates of pre-Vietnam wars were reported at 50 percent or lower. And perhaps it is why Karl Marlantes (2012) claimed his most hauntingly memorable kill was the occasion when he looked a Viet Cong in the eye and paused before killing him.

Reflexive fire training has done away with that pause. In modern combat training, bull's-eye targets have been replaced with man-shaped targets that fall down when shot. Soldiers are trained to fire on order the instant a command is given. This response is overlearned, and it is reinforced — with targets falling down, verbal praise, and medals (Grossman, 2009; Whirley, 2014). On the battlefield, combatants now rarely think before killing; they simply respond. Reflexive fire training interrupts the instinct to avoid killing and removes the service member's moment of decision, leaving him or her no time to consider the moral conflict until after the kill. With the increase of nonuniformed troops and potentially hostile civilians in the modern wars, the probability of postkilling moral conflict (and thereby moral injury) has grown exponentially.

Healing the Heart

Moral injury is caused when one's actions, or the actions of one's peers or leaders, deeply violate one's moral beliefs. The opportunity for healing also lies within one's moral beliefs. Like existing treatments for PTSD (Foa, Hembree, & Rothbaum, 2007; Monson et al., 2006), healing moral injury may involve adapting one's moral beliefs, modifying beliefs about the event, and/or exposure. However, some service members may hold adaptively healthy morals and still have committed atrocities. Exposure may minimize intrusions, but it will not heal the shame of moral violation. Full recovery from moral injury likely involves forgiveness (Drescher et al., 2011; Nakashima Brock & Lettini, 2013). Forgiveness may come from the self, a transcendent being, or society. Should moral injury ultimately be revealed as a public health problem as PTSD has, healing our veterans' wounds will require forgiveness, empathy, and a willingness to hear their stories.

References

Aveni, T. J. (n.d.). S. L. A. Marshall's “Men against fire.” Retrieved from http://www.theppsc.org/Grossman/SLA_Marshall/Main.htm

Buechner, B. (2014, March 20). Moral injury and military psychology. Presented at the meeting of the American Psychological Association Division 19 Student Chapter, Fielding Graduate University, Santa Barbara, CA.

Drescher, K. D., Foy, D. W., Kelly, C., Leshner, A., Schultz, K., & Litz, B. (2011). An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology, 17, 8–13. http://dx.doi.org/ 10.1177/1534765610395615

Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences: Therapist guide. New York: Oxford University Press.

Grossman, D. G. (2009). On killing: The psychological cost of learning to kill in war and society. New York, NY: Back Bay Books.

Guntzel, J. S., Warner, A., Bebinger, M., & Freemark, S. (2013). Invisible injury: Beyond PTSD. Retrieved from http://www.publicinsightnetwork.org/2013/06/21/invisible-injury-beyond-ptsd-illustrated-story/

Kraus, D. (2014, June 21). Moral injury. Presented at Military and Trauma Issues Seminar in association with Divisions 19 and 56 of the American Psychological Association, Memphis, TN.

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. http://dx.doi.org/10.1016/j.cpr.2009.07.003

Marlantes, K. (2012). What it is like to go to war. New York: Glove Press.

Marshall, S. L. A. (2000). Men against fire: The problem of battle command. Norman: Oklahoma University Press. (Original work published 1947)

Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J., Young-Xu, Y., & Stevens, S. P. (2006). Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74, 898–907. http://dx.doi.org/10.1037/0022-006X.74.5.898

Nakashima Brock, R., & Lettini, G. (2013). Soul repair: Recovering from moral injury after war. Boston, MA: Beacon Press.

Nash, W. P., & Litz, B. T. (2013). Moral injury: A mechanism for war-related psychological trauma in military family members. Clinical Child and Family Psychological Review, 16, 365–375. http://dx.doi.org/10.1007/s10567-013-0146-y

Shay, J. (2003). Odysseus in America: Combat trauma and the trials of homecoming. New York, NY: Scribner.

Vargas, A. F., Hanson, T., Kraus, D., Drescher, K., & Foy, D. (2013). Moral injury themes in combat veterans' narrative responses from the National Vietnam Veterans' Readjustment Study. Traumatology, 20, 243–250. http://dx.doi.org/10.1177/1534765613476099

Whirley, J. (2014, June 21). Evidence-based psychotherapies for PTSD. Presented at Military and Trauma Issues Seminar in association with Divisions 19 and 56 of the American Psychological Association, Memphis, TN.