Moral Injury Talks Pt. 1

In early April, BGSP hosted a continuing education event, Moral Injury and the Long Road Home From War. This event featured a talk by Lt. Col. Douglas Pryer, with discussion by psychoanalyst-psychologist Jaine Darwin. We post here LTC Pryer’s talk. Next week we will post Dr. Darwin’s comments.

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By Lt. Col. Douglas Pryer
The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. government.

So, where to begin? When writing about combat veterans, Dr. Meagher, the eminent classicist, likes to emphasize the role that stories play in helping veterans’ lives.  “For veterans,” he recently wrote, “stories are often a matter of life and death, sacred stuff, the road out of darkness, the path to healing.” Or, as Tim O’Brien wrote in The Things They Carried:

All those Stories. Not bloody stories necessarily. Happy stories, too, and even a few peace stories.… That’s what stories are for. Stories are for joining the past to the future. Stories are for those late hours in the night when you can’t remember how you got from where you were to where you are. Stories are for eternity, when memory is erased, when there is nothing to remember except the story.

More observer than participant, Samuel Taylor Coleridge understood the vital role that stories play in healing those who have endured ordeals, as is clear in his poem about an ancient sailor who, after stopping a guest at a wedding—a guest clearly confused and upset by the situation in which he found himself—says these words:

Since then, at an uncertain hour,
That agony returns:
And till my ghastly tale is told,
This heart within me burns.

So, as you no doubt expected (and were probably fearful of), I’ll be sharing a few war stories with you today. Please bear with me. Hopefully, my conceit in doing so will be balanced with enough modest research and useful ideas to make worthwhile the time you spend with me today—and you won’t leave feeling too much like Coleridge’s trapped wedding guest.

Story number one (and the shortest): As a captain and company commander in Baghdad, I earned a Combat Action Badge because, for a period of about a month in 2004, I seemed to attract enemy fire like, as we say in the Ozarks where I was raised, flies are attracted to jam. Whenever I went anywhere in the so-called “Deadly Triangle” south of Baghdad, random fire seemed to hit my vehicle or land close to where I was standing. After the last near-miss, I walked by some soldiers on FOB Chosin. They were playing catch with a football. When they were behind me, one of them threw long over the hands of the intended receiver, and the football seemed to explode by my feet. I dove for cover behind some sandbags.

Those soldiers laughed so hard that at least one was holding his stomach. As I got up, brushed myself off, and walked sheepishly away, one of them called out between laughs: “You’ll be all right, sir.”

Nonetheless, enemy fire didn’t really traumatize me. Perhaps the noise was never loud enough, or metal fragments didn’t come close enough. Extreme fear producing hormones that affected the areas of my brain that regulate emotions, resulting in fears being linked to specific memories and perceptions, is not something I experienced. True, I no longer enjoy fireworks, and the sounds of gunshots and vehicles backfiring can make me jump as I once jumped at FOB Chosin when that football seemed to explode by my feet. But was I traumatized? I wouldn’t call it that. If I suffer from PTSD, it’s a very mild form of this psychological injury.

No, what caused me to live in a state of near-constant grief and sadness, has nothing to do with extreme fear producing hormones that affected the areas of my brain that regulate emotions, lastingly inking fear to specific memories and perceptions. What caused me to suffer from insomnia has nothing to do with life-threatening or physically traumatic events. What caused me, for a time, to be suicidal did not meet the definition for PTSD as this condition is defined in the Diagnostic and Statistical Manual of Mental Disorders (or DSM). The unsettling nature of my most affecting combat experiences is primarily sewn together with a different thread than that of fear. This thread is moral dissonance. When I look back at certain experiences, it is clear to me that others failed to make wise choices. It is obvious that I, too, sometimes failed to make the best decision.  To our shame, we should have known better.

A growing number of mental health experts argue for the existence of a condition that may better explain my symptoms than “PTSD.” Although “moral injury” is not listed in the mental health manual, many argue that the condition is real. Most argue today that moral injury is a condition distinct from but closely associated with PTSD. In perhaps the most influential article written by mental health professionals on the subject, moral injury is defined as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”

PTSD typically involves physically threatening events that induce extreme fear, the argument goes today. Moral injury revolves around questions of identity, whether individual or group.  It involves questions of “home,” of being unable to recognize who we are and where we belong in this world: if you are afflicted with moral injury, to apply the lyrical words of one of my favorite authors, Thomas Wolfe, “you can never go home again”—or at least not to the self and world in which you used to live. PTSD and moral injury share some symptoms. But there are also symptoms unique to moral injury, such as “shame, guilt, demoralization, self-handicapping behaviors . . . and self-harm.” They respond to different treatments: PTSD sufferers may be helped via such physical remedies as drugs and Rapid Eye Movement treatment, but those who have moral injury seem to respond best to counseling and, possibly, ritual.

Why do I believe myself afflicted by moral injury?  Let me the count the ways, or, for you, a couple of the ways. Story number two:

I first met Rob Scheetz during a month-long military exercise near Hohenfels, Germany. He was the executive officer for an infantry company attached to my armor battalion for the exercise. I was a junior captain and battalion S-2 (or staff intelligence officer).

Rob was stocky, square-jawed, and sandy-haired, and he had a brilliant smile. Soon after we met, he told me that he was a military intelligence officer like me. He had been “branch detailed” to serve as an infantry lieutenant, but he would soon transition to intelligence work. So, he said, he wanted to learn anything I could teach him about military intelligence.

I taught him what I knew. Every couple days, he would come into the command post, and we would sit down and talk for a few minutes, usually over cups of awful coffee. Rob, I soon realized, was impossible not to like. Courteous and respectful, his enthusiasm was infectious. You could tell that he genuinely loved the Army, and it was unsurprising when he told me that he wanted to stay in the Army as long as he could. 

Shortly after this training exercise ended, I changed jobs and moved from Baumholder to Wiesbaden. I didn’t see Rob for nearly a year. Then, in November 2003, after we had both deployed with the 1^st Armored Division to Baghdad, I took command of the intelligence company supporting the brigade that Rob still served in.

By this time, Rob was a captain and the S-2 for an infantry battalion. Thanks to his infantry experience and six months in Iraq, he probably already knew more about being the S-2 for a combat arms unit than I did. So, when we talked, we would simply find out how the other was doing, and I would him ask him if there were anything more my company could do to support his battalion. One thing hadn’t changed, though: I always looked forward to seeing him.

After we had been in Iraq about nine months, in early 2004, a full-scale insurgency was born. Our division’s tour was extended, and our brigade’s mission changed. To free up a Marine unit for the second assault on Fallujah, our brigade moved south of Baghdad into what was called Iraq’s “Deadly Triangle.”Huge Iraqi munitions factories and storage areas, which had been thoroughly looted by insurgents, were located there. These looted munitions, especially artillery shells, served as the explosives component for roadside bombs throughout the area.

Our brigade would suffer more casualties during those three months in the Deadly Triangle than we had during the previous year in Baghdad. Nearly everywhere you drove, the hostility of the people could be felt in how they looked at you. More unsettling than the angry glares were the large potholes scattered up and down roads from previously exploded roadside bombs. Anytime you drove anywhere, reaching your destination alive and intact depended upon luck. It truly was like playing a game of Russian roulette.

Soon after our deployment extended, Rob told me that his battalion commander was making him physically investigate roadside bomb explosions. Neither one of us was happy about this task. It was extremely dangerous work for what seemed to be little good purpose, since he was an intelligence officer and not an explosives expert armed with forensic equipment. When approaching a bomb site, his vehicle might detonate an unexploded bomb “daisy-chained” to the exploded one. Or, after the bad guys realized that a team always came to investigate their bombings, a second bomb might be set in deliberate, remote-detonated ambush. The order didn’t make any sense. It was clearly an expression of helpless frustration, intended to serve as a symbol of the battalion commander’s willingness to throw everything he had at the guys who were killing his troops.

One morning in late May, I picked up the flap to leave the cool, dark chow tent at Chosin and, blinking in the blindingly bright sun, saw a fuzzy mixture of shadow and halo, a soldier, walking toward me. My eyes adjusted. It was Rob about to enter and eat breakfast.

Rob smiled, seemingly as happy to see me as I was to see him. He reached out to shake my hand, and I grabbed his right forearm instead, telling him, “You’re a warrior and my brother. So, let’s shake hands like the Romans did.” He played along, grabbing my right forearm, too, and we laughed. He then told me he would soon be travelling to al Hillah, a small city south of the base. I told him I would be out checking on some of my soldiers on another base and would be back later that night. We promised to link-up.

That evening, when I dismounted from my humvee, I learned that Rob had been in a massive roadside bomb explosion. He was fighting for his life, I was told, in the aid station on the other side of the base. I immediately took off in full gear, jogging as fast as I could on the mile run to where Rob lay fighting for his life.

In nightmares, sometimes waking ones, I re-live this run. It’s a new moon, and clouds block any star shine. In pitch blackness, bogged down with battle armor, I’m running as if in quicksand toward the distant light of the aid station—a light that doesn’t seem to draw any closer.

When I finally reached the aid station, of course I couldn’t go inside. So, I waited in the shadows, in the periphery of the only source of light for seemingly countless miles of heavy, thick darkness. When a medic popped his head out to yell something, I yelled back, “Is Captain Scheetz going to be alright?” He shouted back, “He’s hurt really bad. But we think he’s going to pull through.” Relieved, I trudged back through the darkness to my tent. 

Early the next morning, I caught the convoy I had been planning to catch to Baghdad.  Later that day, Rob died. When I heard the news, I couldn’t help but wander dazed to my tent and, in the achingly empty silence there, cry as quietly as I could.

Trying to come to grips with his death, I wrote a short letter to Rob, which I later reorganized thus:

When we last met
Outside,
In noon’s hot light,
I said to you, “Rob, my friend,
Let’s shake hands,
Like the Romans did,”
And you chose to humor me,
Grabbing my forearm,
Smiling, as I gripped your arm,
And I told you,
“It’s good to see you!”
And (probably lying) you agreed,
And I asked you your plans
For the day, and you said
You were traveling south to Al Hillah,
And I told you to be safe–
Or at least something to that effect.

After I learned
Later,
That you had died
On the road to Al Hillah,
Tossed in a
Fiery explosion
That threw men and metal
More than thirty yards,
I thought of our last meeting,
And how fitting
It had been that it had been thus,
Your broad smile no less bright
Than the Iraqi sun,
Your hailing me like the warrior you are—
Weary, yes, but with heart glad
And ready for the journey ahead. 

Well-met, Rob, and God Speed
On the one journey
We all must go on:
We WILL meet again!”

Written in the immediate emotional aftermath of Rob’s death, these words weren’t the healing words I hoped for. They were really words of denial. I was conjuring Rob, trying to bring him back to life, to convince myself that he wasn’t really dead. Did I really believe in a Valhalla in which Rob and I would see each other, have a drink and reminisce about the good, bad old days in Iraq? No, I didn’t. Or, if I did, it was an idea I held onto for only a few days.

What persisted instead was the belief that Rob’s death shouldn’t have happened.

Rob shouldn’t have died. He was performing a stupid, senseless mission—a judgment I should’ve shared with his battalion commander. Moreover, we should’ve redeployed to Germany one month earlier. The situation in Iraq shouldn’t have deteriorated as dramatically as it did. But, we blew it. Paul Bremer and the Coalition Provisional Authority showed staggeringly poor judgment in the decrees they issued, decisions that disenfranchised Sunnis from their new government. Plus, there weren’t enough of the right kind of military forces on the ground, and what units there were tended to alienate Iraqis with harsh, culturally offensive tactics.

I don’t think about Rob every day, but I think about him a lot. Although I never met them, I wonder how his family is doing. I also picture Rob as he was on the morning he was hit, smiling, and I can feel his ghostly fingers on my right forearm, gripping it “like the Romans did.”

And now—without the common courtesy of a decent segue—story number three.

Before I took command of my company in Baghdad, I helped my boss manage interrogation operations for Task Force 1^st Armored Division. When the Abu Ghraib prison was established as the military’s consolidated interrogation facility for Iraq, I regularly called the prison and asked them to pull specific detainees out of the general prison population for interrogation. I had no inkling at the time of the awful abuses prisoners were enduring in the prison’s hard site, where interrogation subjects were housed and questioned.

That inkling came later, in early April 2004, when my battalion commander told me that there was an investigation into serious prisoner abuse at the prison. Suspicion turned to disgust when, a couple weeks later, I viewed the shocking Abu Ghraib photos on television.

For years, I wondered if any of the prisoners I had asked Abu Ghraib interrogators to question were in that naked pyramid. Then I learned that the prisoners in the photos were, for the most part, not interrogation subjects. Although the prosecuted abuses took place where interrogation subjects were held, nearly all of the prisoners in the published photos were common criminals. They had been pulled out of the general population tents by a group of depraved military policemen looking for some late-night fun.

But this fact made me feel only slightly better, since I also learned later that there were photographs of worse abuses that President Obama elected not to release, photographs that involve crimes like rape and may depict prisoners who were interrogation subjects. I learned, too, that Abu Ghraib interrogators had routinely employed such abusive practices as “Forced Nudity” and “Stress Positions” on their subjects—practices I consider torture.

Most American soldiers feel tainted by what happened at the prison. I probably feel tainted more than most. It makes me sick to think that, by my making calls to that prison and asking for certain prisoners to be interrogated, I was likely part of the causal chain that led to the torture of certain Iraqis.

I can’t remember the names of the prisoners I asked Abu Ghraib interrogators to question. If I did and I met them, I don’t know what I would say to them. It wasn’t my fault? I’m sorry?

The concept of moral injury makes sense to me. It fits. Supporting the existence of moral injury is thousands of years of literature. Dr. Jonathan Shay may have popularized the term “moral injury” in his 1994 book, “Achilles in Vietnam,” but the concept is as old as literature. At the heart of The Iliad, Shay argues, is a story of sullied honor.[1] Agamemnon, the Greek army’s commander, “betrays ‘what’s right’ by wrongfully seizing Achilles’ prize of honor,” the captured princess Briseis.[2] Achilles is outraged at the slight, withdraws from the Greek army and the war, and “cares about no one but a small group of combat-proven comrades,” the Myrmidons.[3] Consumed by anger, Achilles slowly withdraws even deeper inward, loving no one but his dear friend Patroclus.[4] When the Trojan hero Hector kills Patroclus, “profound grief and suicidal longing take hold of Achilles.”[5] Achilles “is tortured by guilt and the conviction that he should have died rather than his friend,” and “he goes berserk and commits atrocities against the living and the dead.”[6]

Achilles is one of many heroes of the Trojan War to suffer moral distress. There is also, for example, the Greek hero Ajax the Greater, second among the Greeks only to Achilles in strength of arms. After Achilles is slain by Paris’s arrow, Ajax and Odysseus retrieve Achilles’ body.[7] Odysseus’s eloquence convinces a Greek council to award Achilles’ armor to him rather than to Ajax.[8] Ajax, who had never been injured in battle and fought mighty Hector to three draws, feels slighted.[9] The perceived insult eats at him, driving him temporarily insane. He imagines that a herd of sacred animals are the Greek leaders who betrayed him and slaughters the entire herd.[10] When he recovers, he “is doubly humiliated, religiously defiled, and kills himself by falling on his own sword.”[11]

For Shay, Homer’s The Odyssey is the tale of every combat veteran’s difficult return home, explained largely through metaphor. While lost for ten years, Odysseus visits the Land of the Lotus Eaters. Here, Shay says, Homer describes the combat veteran’s temptation to drown his sorrows in drugs and alcohol.[12] When Odysseus visits Hades, his talks with the shades of former comrades and foes is a description of the difficulty a veteran may have putting his battles behind him, haunted as he may be by painful memories and guilt.[13] Odysseus and his men are tempted toward the rocks by Sirens, who sing promises of truth’s revelation. Shay says that these promises are the “unachievable, toxic quest” that a veteran may pursue to know the ultimate “why” of his war experiences.[14] And when Odysseus returns to Ithaca, like many veterans, he does not really recognize the place. He protects himself by pretending to be someone he is not, and he is disrespected by others. [15] His first nights at home are “troubled, uncomfortable, endangered.”[16]

Homer’s warriors are not the only ones to suffer moral trauma in literature. The classics are rife with other examples. When Oedipus, in the Greek tragedist Sophocles’ famous trilogy of plays, learns that he had unknowingly murdered his father and married his own mother, his sense of dishonor drives him mad, causing him to blind himself and wander raving in exile. Sir Thomas Malory’s Le Morte d’Arthur tells the well-known story of Sir Lancelot and Guinevere, two lovers who, feeling their adulterous affair is responsible for King Arthur’s death, seek solitude and penitence for the rest of their lives. Many of Shakespeare’s warriors—motivated by feelings of grief or guilt—kill themselves, including Othello, Cassius, and, after seeing Caesar’s ghost, Brutus.

Another famous sufferer of moral injury is Kurtz in Joseph Conrad’s Heart of Darkness. Kurtz is the commander of a trading post on a river in the Belgian Congo. Initially an idealistic imperialist, Kurtz witnesses and perpetrates atrocities that rival those of Genghis Khan in type if not in scale. His soul becomes as afflicted as his body, which succumbs to jungle fever. As he dies, he seizes Marlow, the book’s narrator, and cries out madly at Marlow and Life: “The horror! The horror!”

In our era, empirical studies have only recently begun to seriously explore the concept. The results have been interesting. For example, a 1991 study looked at 100 Vietnam veterans with PTSD.[17] The study’s authors found that 19 of these veterans had attempted suicide and 15 more were preoccupied with thoughts of suicide.[18] The authors concluded “that combat guilt was the most significant predictor of both suicide attempts and preoccupation with suicide.”

• A 1997 study found that about three-fourth of a sample of Vietnam veterans suffering from PTSD symptoms have multiple sources of severe war-related guilt, suggesting—and this is my spin—that they may be afflicted with moral injury rather than PTSD.[19]
• A 1998 study, based on a survey of 151 Vietnam combat veterans, associated exposure to atrocities with “PTSD symptom severity, PTSD B (reexperiencing) symptoms, Global Guilt, Guilt Cognitions, and cognitive subscales of Hindsight-Bias/Responsibility and Wrongdoing.”[20]
• The 2006 and 2007 Mental Health Advisory Team (MHAT) surveys of soldiers in Iraq and Afghanistan addressed both their mental health and battlefield conduct. The 2007 survey (MHAT V) questioned 2,295 soldiers in Iraq and 699 in Afghanistan.[21] MHAT V found that “soldiers who screened positive for mental health problems were significantly more likely to report engaging in unethical behaviors,” though its authors did not theorize as to whether unethical behaviors contributed to the mental health  problems or vice versa or both.[22]
• A 2009 study involving 1,200 Vietnam veterans analyzed the impact of killing in war on mental health symptoms.[23] The authors reported “that killing was associated with posttraumatic stress disorder symptoms, dissociation, functional impairment, and violent behaviors.”[24]
• A 2010 study examined data collected from 1,323 male Vietnam veterans while exploring the effects of guilt from abusive combat violence, such as harming prisoners and civilians.[25] The authors found “that guilt may be a mechanism through which abusive violence is related to PTSD and MDD [Major Depressive Disorder] among combat-deployed veterans.”[26]
• A 2010 study examined the effect of directly or indirectly killing others on 2,797 Operation Iraqi Freedom veterans.[27] The authors concluded that “killing was a significant predictor of PTSD symptoms, alcohol abuse, anger, and relationship problems.”[28]
• A 2011 study examined the impact of killing in war based on a survey of 317 Gulf War veterans.[29] The authors found that killing in war is a significant predictor of PTSS [posttraumatic stress symptomatology], frequency and quantity of alcohol use, and problem alcohol use.”[30]

These studies’ conclusions are supplemented by a staggering amount of published anecdotal evidence. Dr. Shay’s, Dr. Nancy Sherman’s, Dr. Edward Tick’s, Dr. Rita Nakashima’s, and Dr. Gabriella Lettini’s work contain scores of veterans’ stories pointing to the existence of moral injury.

Some stories have gained national media attention. There is the sad tale of Alyssa Peterson, a young intelligence analyst who committed suicide in 2003 after being reprimanded for refusing to perform so-called “torture-lite” tactics. There is the story of Levi Darby, who hung himself in April 2007 because he felt guilty for the death of a little Afghan girl: he had gestured to the girl to come get a bottle of water, and when she came forward to get it, she was blown up by a land mine. [31] There is the tale of Daniel Somers, who committed suicide in June of 2012. He had served as an interrogator and humvee gunner for two tours in Iraq. [32] In his suicide note, he pointed to two main sources of distress, a government system that he said was not getting him the help he needed and the [quote unquote] war crimes” that he believed that he had participated in during his first tour in Iraq.[33]

In his book, None of Us Were Like This Before, the journalist Joshua Phillips tells how a group of soldiers at a small jail in Iraq tortured their detainees and how guilt over their deeds later tortured them. The abuse those soldiers inflicted included hanging prisoners from the bars of cages; depriving them of sleep, food, and drink; performing mock executions; making them perform painful physical exercises and assume stress positions; and beating, choking, and waterboarding them.

When they returned home, many of these soldiers struggled with drugs and alcohol, insomnia, high blood pressure, depression, keeping jobs, and suicidal thoughts. They told Phillips that what bothered them the most was their feelings of guilt. Two of them, Adam Gray and Jonathan Millantz, eventually died under circumstances their friends and families believe was suicide.

Moral conflict is not unique to warriors. Warriors in combat just tend to experience it more deeply. When they go to war, they enter another world that is far removed morally from the one they grew up in. No longer are they always encouraged to show compassion toward others. The principle that they should treat others as they themselves would like to be treated must often be rejected. They do not want to be killed themselves, yet they must sometimes kill others. Compassion, the “Golden Rule,” and laws and mores that are normal at home are greatly modified on battlefields, applying to a warrior’s dealings with his comrades-in-arms but only in special circumstances to his interactions with “enemy” troops.

In the alien world that warriors enter, they may assume an identity—a posture toward large groups of fellow human beings—that seems just as alien and remote to them as the land and war in which they fight. This alien identity may or may not be something they can easily live with.

Dr. Shay, who counseled hundreds of veterans of the Vietnam War, believes that it is the moral component—the perceived violation of “what’s right”—of any traumatic event that triggers the most serious and enduring psychological effects. If true, this truth is sadly ironic, for moral injury is neither recognized by military leaders nor treated by military psychologists. One problem is that the concept isn’t culturally palatable. Military leaders say that the term implies that service member suffering from the condition actually did or witnessed something ethically wrong. These leaders miss the point. It is not the ethical standards of the nation, organization, or these leaders that matters in such cases. It is what service members themselves feel about the rightness of such events that is important. Although killing someone, for example, may sometimes be necessary in order to prevent less harm, it doesn’t mean that this killing always, or even usually, feels right.

Adding to the sense of pathos here is that moral injury causes mental torture to the very troops whose care is entrusted to American leaders. It leads service members to try to drown their sorrows in alcohol or the euphoria of drugs, to be involuntarily separated from the service due to disciplinary action, or to voluntarily leave the service—or the world, by killing themselves—because they feel they cannot cope anymore. It greatly burdens the U.S. military and civilian healthcare systems. It hurts the ability of veterans to positively contribute to society. It distresses and sometimes leads to the physical harm of those who interact with afflicted soldiers. Of all these adverse effects of moral injury, it is the role that moral injury may play in the U.S. military’s high suicide rate that has attracted the most attention.[34]

The statement that “the U.S. military currently has a suicide problem” is an understatement. Throughout the nineties, the active-duty suicide rates of the four major services remained steady at about 10 suicides per 100,000 service members. Since 2003, this active-duty rate has doubled for the Navy and Air Force, making it comparable to the rate among U.S. civilians of like age and gender. But this rate also more than doubled among Marines and tripled among soldiers.

It is reasonable to suspect that moral injury has something to do with this increased suicide rate. Certainly, the potential for moral injury within the ranks and among veterans is great. The military’s 2006 and 2007 mental health surveys of soldiers and Marines in Iraq and Afghanistan found that ten percent of these troops believed that they had mistreated noncombatants or damaged property “when it was not necessary.” If this ratio holds true during the other years of these conflicts—and there is little reason to think that it does not—then nearly 200,000 soldiers and Marines may have cause to suffer moral distress from their actions downrange. This number does not include those who may suffer from other potential sources of moral injury, such as the legally justifiable killing of enemy combatants and the unintentional killing of noncombatants (for even legally justifiable actions can greatly trouble warriors).

Military leaders may minimize the extent of these potential sources of moral injury, saying, for instance, that so-called “enhanced” interrogation techniques were rarely used and, when used, rarely devolved into real torture. Nonetheless, it is obvious from surveys and books that a substantial number of service members believe that they did something wrong, perhaps even terribly wrong, downrange.

This noted, moral injury cannot be solely responsible for our military’s increased suicide rate: PTSD and traumatic brain injury have also been associated with increased suicide risk and no doubt deserve a share of the blame. High operational tempo deserves a share, too. Since 9/11, even service members who did not deploy were often placed under great strain. I knew a recruiter, for example, who nearly killed himself, and the strain that higher enlistment quotas placed on both him and his marriage had something to do with it. But I believe that moral injury is at least partially responsible because of what literature teaches us, what some empirical studies have stated, and what various published stories of service member suicides have reported. And I believe this is so because of my own flirtation with suicide a couple years ago.

This brings me to my last story. This injury took place when I was deployed, but it has nothing to do with combat.  It’s the story of my oldest daughter Desiree, who, on Winters Solstice 2011, on the shortest and darkest day of the year, took her own life.

When her mother and I were together, Desi was very much “Daddy’s Little Girl.” She was happy-go-lucky, vivacious, and intelligent. She was artistic, often drawing, painting, and writing poetry.

Eight years before Desi’s death and five years after I had divorced her mother, someone her mother trusted impregnated Desi. Desi later said that this boy, who was nearly seven years her senior, had molested her for years. Since the molester was still a minor at the time of his crimes, there was nothing the law could do to punish him.

I was in Iraq when I learned what had happened to Desi. I was in Afghanistan when I learned of her death. Her suicide wasn’t her first attempt, so it wasn’t unexpected. This didn’t make the news any less devastating. For me, the long winter’s night of my daughter’s death did not last just one day. It lasted 24 hours a day, seven days a week. It followed me to America and back to Afghanistan. It permeated me, enveloped me, and dulled my senses. When I wasn’t numb, I felt crazed with grief.

For a few months afterwards, when walking around Kabul and Bagram with a pistol and ammo, I thought of ending my own life. It wasn’t an ending I sought but a beginning, a chance to see Desi and comfort her for as long as she needed. I desperately wanted to hold her, to talk to her, to tell her how much I loved her, and I could not think of any other way I might be able to do that than to “shuffle this mortal coil.”

I had recurring fantasies in which I met Desi in an afterlife. Sometimes, I travelled to a pit in Hell to see her, and I was able, like Orpheus, to lead her to the surface. Other times, I was trapped there with her, but found solace in seeing her, talking to her, sharing her torments with her, holding her hand, comforting her as I had apparently failed to do when she lived. Still other times I dreamed that I met Desi in a place of beauty and light, a place where we could share smiles and laughter and hug and where, too, I could tell her how much I loved her, and how sorry I was that her life had not received the ending on earth that she had deserved.

I thought constantly of Desi and of the weapon and magazines in my holster. The holster came to feel immensely heavy, as if it were a great secret burden like the One Ring that Frodo carries into Mordor. At night, whenever I returned to my room, the first thing I would do would be to secure it in my locker so as to try to put the pistol out of my mind.

Two thoughts saved me. The first was that there might not be an afterlife, and if there were, I couldn’t be sure I would be allowed to see Desi again. The second thought was even more important: I couldn’t do that to my other loved ones, especially my wife and two much younger children. They needed me, and they would be deeply hurt by my doing that.

If for just a few seconds these two thoughts had abandoned me, I wouldn’t have returned home. As it was, they were barely enough.

Before Desi died, she was diagnosed with PTSD and dissociative personality disorder. I believe that both conditions for Desi were a type of “identity disorder.” At bottom, Desi did not like who she had become, and she could not go back to who she had once been.

When I called her on the phone, she often sounded depressed. Her poetry, like the following short lyric, often focused on death and her escaping to a better world and self:

Just another Cloudy Day by Desiree Pryer

A home of white walls and no pictures to frame,
The cries of the darkness calling my name,
A plant almost dead- dead today,
I clean up the blood, and it all falls away.

I leave in a dream to mangoes and peaches,
To sunshine and smiles and castles on beaches,
I walk on the sand, dreaming it all:
The tide pulls me in, and I drown in white walls.

The fifth and sixth lines of this poem I had inscribed on her tombstone at a cemetery in Lawrence, Kansas.

I didn’t see Desi much after the divorce—a total of three summers and a handful of weeks. The last few years, after she had her baby, I hardly saw her at all, but I talked to her on the phone regularly.

Desi usually only contacted me when “she was in a good place,” when she could sound happy and giggle and pretend for the both of us she was the same girl she had been when she was little. But, near the end, she wrote two despairing emails in which she told me that she wasn’t the same little girl she used to be and that she never would be this girl again. “Damaged” is how she described herself in one email.

In reply, I told her that she should try to be positive and to not worry about things, and to remember that I loved her very much and always would. I tried to emphasize that last point.

I suspect today that what she heard was not what I wanted her to hear. Instead of hearing how much I loved her, what she must have heard loudest was my telling her to ignore what she could not ignore. What she heard was silence where she needed to hear that I was listening to her, that I thought it okay for her to be angry at the world. What she needed to hear most was that I accepted that she could no longer be the same person she once was.

Why did I insist that she focus on the positive? Why didn’t I allow her to be angry and sad and morbidly obsessed with death? Was I still in denial? Or, was the stoic outlook—the idea that anyone can overcome anything if only they have the right attitude—that I had adopted over my years in the Army driving my inability to acknowledge what she needed me to? Or, was this insistence there simply because I loved her, wanted her to be happy, was distraught by her unhappiness, distressed by her poetry, and was deeply afraid she would kill herself? I struggle today to answer these questions without feelings of guilt and shame.

The hardest self-incrimination to deal with has been the thought that, if I hadn’t selfishly divorced her mother, Desi would’ve turned out all right. She would’ve gone to college, become a writer or artist, gotten married, had children, and outlived her father by at least a couple decades.

I loved and missed her terribly. Still do. But it wasn’t so much the missing her that made me think of taking my own life. It was the way her life had ended that devastated me, that, above nearly all else, I needed to comfort her. Desi didn’t deserve that ending. She didn’t deserve to be molested and raped. She didn’t deserve to die so young. In my fantasies, I played the role that I had failed to play during her life—the rescuing knight riding in to give her life a meaning and ending that she better deserved. Or, if I weren’t imagining myself as her knight in white armor, I was dreaming that her afterlife was the happy ending that she had deserved all along—an ending that I, too, could now share with her. 

Losing Desi has somehow amplified the effects of the moral conflict I feel regarding certain combat experiences. It’s as if Rob, Abu Ghraib, and other questionable things that I experienced downrange were Poe’s “Raven,” tapping at my identity, weakening the window pane of my self, my soul as it were, and my realizing that Desi was dead cracked the glass. Her death has had the strange retroactive effect of making me more upset about these previous things than I once was. Since she died, I think about Rob, Abu Ghraib, and other things than I once did. It’s no wonder PTSD’s symptoms can take years to surface, for when this occurs, it may not be PTSD but moral injury that is the underlying problem, and it can take years for one’s identity—how one wants to see the world and oneself—to break under the accumulated weight of moral dissonance.

As a result of moral injury, I react differently to a lot of things than I used to. I become far more upset than I once did when a character in a movie or a book I’m reading movie is abused or loses a comrade or loved one. I find myself empathizing with cartoon characters, for chrissake, even crying when they suffer some tragedy that I know isn’t real. It now seems to me that the self is nothing more than an artificial construct whose most useful function is to maintain some degree of separation between ourselves and the other—other people, past memories. Or, as R.E.M. phrased it in their song “Losing My Religion”: “Oh life, it’s bigger. It’s bigger than you. And you are not me.” That is, the very first condition of a healthy mind is the ability to draw the distinction between what is “me” and what is “not me.” Moral injury—somehow, some way—damages our ability to draw this fundamental distinction.

An idea that makes more sense to me now than it used to is Carl Jung’s idea of the shadow self, a collection of seemingly random, destructive thoughts, impulses, and feelings that your cultivated ego serves to buffer you against. If you have a strong ego or identity, you can readily reject harmful thoughts by saying: “That is not me. There is no way ‘I’ would do something like that.” However, when someone has committed or witnessed or been victimized by an act that he believes to be profoundly wrong, his sense of identity can weaken or, worse, dissipate entirely. In that state, people can flounder in a hurricane of wild thoughts and feeling. They can be at a loss on how to cope with impulses that once they could easily manage or dismiss. Even if the morally injured do not give in to such destructive impulses, the thought that the unknown person that they have become could someday do so may unnerve and upset them, causing them to seek refuge by withdrawing from others—or to decisively protect themselves from self-censure and others from harm by killing themselves.

So, we come to the end of my talk. What I set out to do was to provide you evidence, some personal, some based on a modest amount of research, that moral injury is real and its effects are significant, and that these effects are the most enduring, resistant to treatment, and potentially harmful effects commonly and incorrectly associated with PTSD. In my case, the effects have not ruined my life. Although less effective in some ways than I once was, I’m not dysfunctional. I don’t live on the streets. I have a family for whom I’m still able to provide. But, clearly, moral injury has dramatically affected my life. It’s not just the obvious symptoms, some of which you might find in the DSM associated with conditions that have labels other than “moral injury”; it’s the fact that I have come to care so deeply about moral psychology. Ten years ago, I considered morality in any form to be a boring subject that had less to do with the way the world is than what it ought to be. Only self-righteous theologians and philosophers sought expertise in morality, I thought. I now realize that this view was immature and inexperienced, that perceptions of right and wrong matter deeply, that the effects of these perceptions are rooted in human biology, and that without the ability to see other human beings as beings like ourselves deserving to be treated as we would like to be treated we could not live in communities and nations. Quite simply, if moral perceptions were not an integral part of our biological make-up, we would not be as successful of a species as we’ve been.

In addition to making the case for moral injury, I wanted to convey a couple of ideas to you that ring true for me regarding what it means to be a combat veteran, over and above those experiences you see in the movies, which largely consists of loud explosions and other forms of adrenalin rushes. Hopefully, I have done this. However, what I wanted to do—what I want to do—most of all is convince at least one of you to make more of a difference with regard to the study of moral injury than it may have occurred to you to make. In a presentation I gave last year to a group of field group officers at the Army’s Command and General Staff College, my main point was that it is the job of military leaders, not mental health professionals, to limit occurrences of moral injury. If Alyssa Peterson, for example, had not felt pressured by her leaders to torture, she would probably not have felt so conflicted as to take her own life. Mental health professionals, though, have a huge role to play with regard to the study and treatment of moral injury. The condition has not even been convincingly and authoritatively defined. Is moral injury a type of PTSD, as Dr. Shay argues? Or, is the condition related to but distinct from PTSD, as psychologists like Dr Brett Litz and Dr Bill Nash argue? Or is it, as I believe it to be, a condition that can underlie and intersect many cases of various psychological injuries, not just PTSD but, for example, Major Depressive Disorder and dissociative disorder? Other questions still unanswered:  if moral injury is at bottom a identity disorder, what does this type of disorder look like, at the biochemical level? Can the human soul even be thus dissected into component molecules? Can it be treated with a medicine or medical procedure? How is it best treated? Counseling in various forms can be effective, but which form when works best for whom? And what about ritual? Rituals once played a role in helping ancient warriors build new identities: can we meaningfully replicate such rituals today? If so, what and when is the most effective form of ritual?

There are more questions than answers about moral injury and not nearly enough research being done. This lack of research is most obvious within our military. Our military, for instance, collects a great deal of data related to suicide. When a service member commits suicide, leaders know if the victim fell into specific behavioral categories, such as alcohol and drug abuse, financial distress, disciplinary issues, and relationship issues. But moral dissonance goes unexplored. Leaders may know that a soldier drank too much, but they rarely know what drove them to drink. Also, when service members redeploy from a combat zone, they take a post-deployment questionnaire. This questionnaire asks a lot of questions directly linked to conditions described in the DSM. It does not, however, ask the simple question if service members feel distressed by anything they did or witnessed downrange, whether it be killing, prisoner abuse, or some other activity. Such questions are too hard, too uncomfortable to ask. This creates a Catch 22: without unassailable conclusions drawn from sufficient data and research, there can seem to be no clear need to collect the data needed to reach these unassailable conclusions. But it is impossible to reach such conclusions without sufficient data.

There is hope, though. The Veterans Administration takes the concept of moral injury seriously and some studies, as I cited earlier, has already been done involving combat veterans who have left the service. It is not nearly enough, though. So, I leave you with this one sincere request: if you can make more of a difference here, please do. There is a LOT of room—and a lot of need—for you to make a difference.

[1] Jonathan Shay, Achilles in Vietnam: Combat Trauma and the Undoing of Character, New York: Scribner, 1994,  xx-xi

[2] Ibid.

[3] Ibid.

[4] Ibid.

[5] Ibid.

[6] Ibid.

[7] Shay, Odysseus in America, 76-77. The story of Ajax as told by Shay derives from a play of Sophocles.

[8] Ibid.

[9] Ibid.

[10] Ibid.

[11] Ibid.

[12] Ibid., 36.

[13] Ibid., 80-81.

[14] Ibid., 87.

[15] Ibid., 246

[16] Ibid.

[17] H. Hendin, A.P. Haas, “Suicide and guilt as manifestations of PTSD in Vietnam combat veterans,” American Journal of Psychiatry, May 1991: 586-91.

[18] Ibid.

[19] E.S. Kubany, F.R. Abueg, W.L. Kilauano, F.P. Manke, A.S. Kaplan, “Development and validation of the sources of trauma,” Journal of Traumatic Stress, April 1997: 235-58.

[20] J.C. Beckham, M.E. Feldman, A.C. Kirby, “Atrocities exposure in Vietnam combat veterans with chronic posttraumatic stress disorder: relationship to combat exposure, symptom severity, guilt, and interpersonal violence,” Journal of Traumatic Stress, October 1998: 777-85; “Moral Injury in Veterans of War,” Maguen and Litz, 3.

[21] Office of the Surgeon Multi-National Force-Iraq and the Office of The Surgeon General United States Army Medical Command, Mental Health Advisory Team (MHAT) V: Operation Iraqi Freedom 06-08: Iraq Operation Enduring Freedom 8: Afghanistan, Washington, D.C.: Department of Defense, 14 February 2008, 4.

[22] Ibid., 12

[23] S. Maguen, D.D. Luxton, N.A. Skopp, G.A. Gahm, M.A. Reger, T.J. Metzler, C.R. Marmar, “Killing in combat, mental health symptoms, and suicidal ideation in Iraq War Veterans,” Journal of Anxiety Disorders, May 2011: 563-7.

[24] “Moral Injury in Veterans of War,” Maguen and Brett Litz, 4.

[25] B.P. Marx, K.M. Foley, B.A. Feinstein, E.J. Wolf, D.G. Kaloupek, T.M. Keane, “Combat-related guilt mediates the relations between exposure to combat-related abusive violence and psychiatric diagnoses,” Depression and Anxiety, March 2010: 287-93.

[26] “Moral Injury in Veterans of War,” Maguen and Litz, 4.

[27] S. Maguen, B.A. Lucenko, M.A. Reger, G.A. Gahm, B.T. Litz, K.H. Seal, S.J. Knight, C.R. Marmar, “The impact of reported direct and indirect killing on mental health symptoms in Iraq War veterans,” Journal of Traumatic Stress, February 2010: 86-90.

[28] “Moral Injury in Veterans of War,” Maguen and Litz, 4.

[29] S. Maguen, Dawn S. Vogt, Lynda A. King, Daniel W. King, Brett T. Litz, Sara J. Knight, Charles R. Marmar, “The impact of killing on mental health symptoms in Gulf War veterans,” Psychological Trauma: Theory, Research, Practice, and Policy, March 2011: 21-26.

[30] “Moral Injury in Veterans of War,” Maguen and Litz, 4.

[31] Moni Basu, “Why suicide rate among veterans may be more than 22 a day,” CNN, November 14, 2013, http://www.cnn.com/2013/09/21/us/22-veteran-suicides-a-day/ (accessed May 26, 2014). The story of Levi Darby in this paragraph is taken entirely from this article.

[32] Daniel Somers, “I Am Sorry That It Has Come to This”: A Soldier’s Last Words,” Gawker, June 22, 2013, http://gawker.com/i-am-sorry-that-it-has-come-to-this-a-soldiers-last-534538357 (accessed May 26, 2014).

[33] Ibid.

[34] Lieutenant Colonel Douglas A. Pryer, Moral Injury and the American Soldier, Cicero Magazine (Nov. 23, 2014, 1:12 PM), http://ciceromagazine.com/features/moral-injury-and-the-american-soldier/.