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. Last week we posted the talk by LTC Pryer. This week we post Dr. Darwin’s comments.
By Jaine Darwin, Psy.D., ABPP
I am pleased to be asked to discuss LTC Pryer’s talk, a talk I processed through multiple lenses as a psychoanalyst who has worked with trauma for the past thirty years, as someone who Co-founded and Co-directed a pro bono mental health project working with family of service members serving in Iraq and Afghanistan and as the daughter of a man who served and was wounded in WWII. First I would like to thank LTC Pryer for his service and to admire the curiosity and courage it takes to enter the alien culture of mental health and to ask the mental health professionals to enter the culture of the military. This issue of culture impacts the concept of moral injury as I will discuss later.
The wars in Afghanistan and Iraq were notable for their length, for the multiple deployments, for being fought by an all volunteer fighting force and for signature wounds, PTSD and TBI, Traumatic brain injury, that were invisible to the untrained eye. They involved 360 degree kill zones with no safe area. With IED’s, improvised explosive devices, and suicide bombers, the green zone was a concept, not a reality. It was as if we were designing a breeding ground for injury and trauma, physical, emotional and moral.
Jonathan Shay views PTSD in service members as a wound of war. I would suggest more generically that PTSD is a wound of living; where assaults by another person, by society or by acts of nature cause us harm. While Edward Tick describes PTSD as an identity disorder, I think of PTSD as a disorder of meaning making. The feelings of helplessness that are a prerequisite for trauma destroy the sufferer’s sense of the world as safe place in which bad things happen to other people. Once one loses the sense of omnipotence that guards us, we are forced to grieve for the loss of the safe world and to learn to accurately assess and cope with omnipresent vulnerability. I would say the same thing about moral injury. To find one is capable of violating core beliefs, capable of committing previously unthinkable acts necessitates grieving for the loss of our unquestionable faith in our moral compasses. For this reason, I find myself slipping into the phrase “ moral trauma” when I speak of moral injury. Leonard Shengold’s book (1991) on the effects of child abuse and deprivation was called Soul Murder, and moral injury endangers souls.
I think we are talking about complex trauma, a result of repeated and prolonged exposure to external situations that bring about feelings of fear and helplessness. Eventually the trauma inducing events come to feel expected and the adaptive responses to trauma like dissociation and numbing become predominate even in the absence of impending threat. Complex trauma takes place in settings where there is no escape. Fighting in the war is one of those settings. The kind of moral injury developed by soldiers and marines is complex as well, rarely based on one single act of violating one’s beliefs; more likely based on cumulative events that first jar and then disable a service member’s moral compass. The concept of moral injury is important because we are then focused on shame and guilt, which are also two major aspects of trauma, the shame and guilt of the victim. Moral injury also throws us a certain curve, as we are accustomed to focus on victims not on those who feel guilt and shame for actions they committed. We must also recognize that many of our military stand in both categories of doer and done to.
The language of work with the trauma utilizes the words, victim, perpetrator and bystander. The military rarely uses the word victim except when the source of the injury is inanimate like an IED. We talk about turning victims into survivors. The military is more apt to talk about returning warriors to service as they do in the Wounded Warrior Program. How might this impact treatment and necessitate the emphasis on a term like moral injury? Most victims of trauma feel shame that they “allowed” things to be done to them, often a denial of the true helplessness that defines victimhood. They feel guilt because of actions they did not take. Some also feel guilt if attempts to save themselves were at the expense of others, like escaping and leaving behind another victim, or in extreme cases, being forced to perpetrate themselves to escape further pain or punishment. Our current view does not easily integrate the guiding principles of military service in war where the top priorities are doing the mission and loyalty to one’s comrades that guarantee the cohesion necessary to accomplish this; where harm to the enemy may be seen as necessary for doing the mission or as collateral damage. How does the soldier or marine deal with being a patriot and later thinking of the self as perpetrator?
We live in a culture that maintains the status quo by creating categories of otherness. We create binaries of us and them to distance ourselves One of these binaries is civilian and military, easily maintained because less than two percent of the population serve in our all volunteer military. I think both the military and the civilians maintain this binary. When Ken Reich and I began to set up a program providing pro bono mental health services to families of service members, we were viewed with a combination of distrust and contempt. We viewed the military as other too. Our first step in relationship building was to learn about military culture. We quickly learned that service members have two families, their family at home and their family of comrades with whom they fight. We can all understand the extraordinary acts committed in the name of protecting family. This is a necessary lens for viewing actions taking place in the frenzy of service in the war. We began to collapse the sense of otherness that separated us.
We learned that service members assume non-military, including family members, will neither understand nor be able to bear their war stories. As LTC Pryer emphasizes, service members may not be able to bear their own lived stories. They may be correct because until we can suspend our judgments and look through their eyes, the stories may be too painful to bear. We too must find a way to alter our moral schemas to separate the doer from the deed. Ideals are theoretical until we are challenged in real time. We also know from the work of Stanley Milgram and of Phil Zimbardo, that many of us will do things that might harm others under certain circumstances.
I want to discuss shame and guilt, topics of great interest to psychoanalysts.
Helen Block Lewis, the mother of Judith Herman who wrote Trauma and Recovery believed that most psychological functioning was motivated by efforts to avoid feelings of shame and guilt. Guilt is the feeling when we feel we have wronged another and shame is the feeling when we have disappointed ourselves. We all do things for which shame and guilt are appropriate responses and serve to help us develop conscience.
Shame and guilt become pathogenic when these feelings are disproportionate to the deeds or when who we are becomes the same as what we did. Many good people do bad things without becoming bad people. Those suffering from moral injury need to be encouraged to separate the act from the actor or to find ways to make room for parts of the self that in retrospect committed bad acts. This may require having someone bear witness to the shame and the guilt, to help find acts of restorative justice or embarking on a survivor mission that attempts to utilize the painful event as a motivation for corrective action. I would suggest LTC Pryer’s effort to foster awareness of moral injury is just such a survivor mission. The process must begin with being able and willing to tell one’s story, not easy when it is tinged with shame and guilt. What must we do as therapists?
We must stop “othering” and acknowledge our own potential to commit bad acts. We must help the person tell the story at a pace that allows them to regulate affect and not become flooded. We must resist the temptation to say “its okay”, as we are not there to absolve. For the moral injury to heal, only the doer can absolve or forgive.
When one does manualized therapies for PTSD like Exposure Therapy or Cognitive Behavioral Therapy, the need to separate out moral injury is greater than for those of us who work psychodynamically. We understand that work with trauma involves dealing with shame and guilt. Again the military culture continues to stigmatize the need for mental health services, so the term injury is preferable to a diagnostic label.
Despite the millions of dollars spent on attempting to reduce the rate of suicide among veterans, there has been little success in lowering the rate of suicides. In fact, between 2008 and 2014 the rate increased from 18 successful suicides a day to 22 successful suicides a day in military veterans. I think some of this results from the continued ambivalence about treatment where the military would like to find a fix for what has to be a long process of healing. Additionally, the realization that one suffers from moral injury may develop because of new triggers that free a memory or because of Freud’s concept nachtraglichkeit. Freud understood nachtraglichkeit as a change in the way a past event is interpreted as psychic development progresses. Only when a veteran becomes a father, may he feel horror about the pain he inflicted by killing someone else’s father in war.
I realize as the daughter of a WWII veteran how actively we colluded with my father not to elicit the telling of his war experience even as he compulsively watched Victory at Sea or volunteered for a veteran’s organization for many years. Only as I began working with military families and he was reaching senescence did we attempt to talk. The story I heard, tinged with some dementia, was about embarrassment for being awarded a bronze star for “killing some Germans, because if we had not killed them, they would have killed us.’ To him, self-defense did not seem like an act of bravery. He also expressed regret at never having fired his gun by which I was confused as he was a mortar gunner. I think he meant that he had never aimed his own rifle at someone. Interestingly, his moral injury came from failing to act. In my work with military families, few of the returning soldiers and marines wanted to tell their stories in words, even as we saw them tell their stories wordlessly in isolating themselves, in heavy partying in younger soldiers, in frequent nightmares. Paula Caplan in her book, When Jane and Johnny Come Marching Home, makes a case for PTSD not being a disorder and not requiring professional help. She proposes that our responsibility as citizens is to listen to the experiences of our veterans.
I think she would say the same thing about moral injury. She is partly right. I do think we need to understand PTSD and moral injury as natural sequelae of war. I do not think we can expect the untrained to understand the complex task of helping someone metabolize the emotional and moral assaults of war.
I want to close by acknowledging the service LTC Pryer performs in alerting us to the category of moral injury as distinct from PTSD. I want to urge us to think together how the 98% of us who did not serve can repay the 2% who did by offering them the support they need to heal from the physical, moral, and emotional injuries of war.