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Jim Meyer
Personal Research
6.16.2014
Moral Injury

This juggernaut of war has crushed millions of humankind. Its savagery and decadence is

consummate. Such butchery has patently marked all the wars of this century and before. This

cannibalization of mankind on its own is unparalleled. Scenes of human massacre that few persons would

believe will be imprinted perpetually in the minds of the combatants. Many of those who experience the

immoral, offensive and degrading trauma of war can be physically and psychologically scared indefinitely.

Their sense of what is right and wrong is in constant conflict. The tragedy of war and incomprehensible

death will change whoever you thought you were and whatever you think you will become when you

encounter its indescribable cruelty.

The ferocity of combat is the final test for mankind. No other activity produces such an

amplification of emotions. No other activity is so final in its consequences. We often have an enigmatic

relationship with combat and war; sometimes it is venerated and other times abhorrent. Perhaps this

quote put some context to war. The sheer terrors of knowing that the next one is going to have your name

on it, when that goes on and on and on...you get a strange feeling in which you seem to become detached...

but who cares. And you learn to sort of live with itYou will either survive or you will not. So theres

really nothing you can do. And you just take it. Sidney Phillips, THE WAR

For centuries we have seen victims of war; soldiers who have had numerous physical injuries that

last throughout their life. With the advent of military arsenals capable of world destruction on a

horrendous scale we can see the devastation on the human psyche. However, during the 20th century,

little was acknowledged about the emotional toll of war. It wasnt until a psychologically study was

outlined that we began to understand what was happening to them. I want to start with some history of

the psychological effects war has brought to the 19th and 20th century.

During the American Civil War, after insanity, nostalgia was the second major diagnostic

category used during the Civil War to term what we think of today as a stress disorder. In the seventeenth

century any disorder associated with depression or changes in personality was termed melancholy or

nostalgia. Daniel Greenfield, said in the Journal of Psychiatry & Law symptoms analogous to PTSD were

called Soldiers Heart and Da Costa Syndrome during the mid to late 19th century. During the Civil War
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era doctor Da Costa studied this problem in the 19th century. Doctor Jacob Mendez da Costa studied Civil

War veterans in the United States; he found that many of them suffered from anxiety and shortness of

breath. He called this syndrome "Soldier's Heart, Irritable Heart and Exhausted Heart. But it also came

to be called Da Costa Syndrome after doctor Jacob Mendez da Costa There is little question that the

Civil War psychologically damaged its soldiers. Many soldiers fighting in this war seemed to have more

severe symptoms if they attacked or were attacked with a knife or bayonet (Bourke, 2011). The closer the

actual distance between soldiers, the worse the symptoms would become. To defeat the enemy, one had to

stare into their eyes and then take their life with bayonet or firearm. Hand to hand combat was without

doubt one of the leading causes in the birth of psychological distress. This antiquated method of fighting

is enormously personal and had an extraordinary deleterious consequence on a soldiers psyche.

What established the term nostalgia for the typical soldier during the combat? Francis Clarke 1

acknowledged that the fracturing of family ties as the most upsetting trials that a soldier could experience.

Considered as a mental disease there can be little doubt that the primary phenomenon of this state is

mental and psychological; it belongs to the class melancholia. Melancholia was a mental condition

consisting of a manic-depressive condition characterized by hallucinations and delusions. It is an acute

mental depression with an unassailable yearning for home that soon produces a state of cachexy (a

profound and patent state of constitutional disorder; overall ill health.)

With the arrival of World War I, (the Great War during 1914-1918) Shell Shock2 was

considered a psychiatric disorder resulting from injury to the psychological part of the soldier during

warfare. Smith and Pear however preferred the term, war strain to shell shock as they felt the trigger for

war strain was reflected in an intense emotional arousal and the subsequent suppression of sympathy for

others, as well as fear (Smith & Pear, 1918). It was felt that the shells formed a concussion that

interrupted the physiology of the brain. While the totality of factors expositionally added to the total

misery, it was primarily the artillery shelling which really broke mens psyche or perhaps more aptly their

inner self. Wounded soldiers had a shocked unblinking robot like stare that was a common symptom of

1 Clark, Francis, War Stories: Suffering and Sacrifice in the Civil War North

2 The term was first published in 1915 in The Lancet by Charles Myers.
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shell-shock. It was essentially a helpless reaction to the intensity of conflict. The term shell shock came

into use to reflect a presumed connection between psychological symptoms and the explosions from

artillery shells. It was considered a crushing stress disorder occurring in soldiers, particularly those

engaged in close one on one combat, characterized by extreme autonomic stimulation. Adam Hochschild

commented that, Simply put, after even the most obedient soldier had enough shells rain down on him,

without any means of fighting back, he often lost all self-control.3 Cases of shell shock were also

construed as a lack of moral fiber. (It is of interest that it was also considered a lack of moral fiber which

we will take up later.) It entered into widespread public imagination after 1915 and was known as the

signature injury of the war. While it was acknowledged that the trauma of war could cause men to break,

a lasting incident was also suggestive of a hidden lack of character. Consequently, some men suffering

from shell shock were put on trial for military crimes such as: going AWOL, desertion and cowardice. One

diagnosis that gained little currency was Freuds war neurosis. Freud felt it brought about an inner

conflict between a soldiers war ego and his peace ego. Another diagnosis which accrued little traction

was called neurasthenia: The mental troubles are many and marked; on the emotional side...On the

intellectual side, lessened power of attention, defective memory and will power.

When World War II came in 1939-1945 the name was changed to Battle Fatigue also called

Combat Fatigue. It was also referred to as Combat Stress Reaction (CSR), some psychiatric

professionals also used Gross Stress Reaction (GSR)4 to refer to shell shock it is a psychological disorder

that progressed in some soldiers who had suffered and agonized over major traumatic experiences in war.

However, this diagnosis (GRS) served as a proxy, due to the want by psychiatrists of having a more

meaningful definition. CSR is a severe response that embraces a range of behaviors ensuing from the

stress and trauma of combat that decrease the soldiers fighting effectiveness. Combat stress was seen as

psychological disintegration suffered during the stresses of battle (Watson, 1978, pg. 233). S. E

Ambrose noted, The experiences of men in combat produce emotions stronger than civilians can know,

emotions of terror, panic, anger, sorrowand each of these feelings drained energy and mental stability

3 Hochschild, Adam (2012). To End All Wars - a story of loyalty and rebellion, 1914-1918. Boston, New York:
Mariner Books, Houghton, Mifflin Harcourt. pp. xv, 242, 348.

4 This was written into the Diagnostic and Statistical Manual in 1952, the DSM-I (Andreasen,
2011).
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(Ambrose, 1992, pg. 203). The most common symptoms are fatigue, sluggish reaction times, vacillation,

withdrawal from one's surroundings and helplessness to prioritize.The person is classically traumatized

with symptoms including depression, excessive irritability and recurrent nightmares. It became apparent

it was not just the weak in character who were falling apart. Near the end of World War II terms like

combat neurosis began to shift or give way to the term combat exhaustion which was very similar to

Combat Fatigue. Author Paul Fussell said the term combat exhaustion as well as the term battle

fatigue suggest a little rest would be enough to restore to useful duty a soldier who would be more

honestly designated as insane. Fussell quoted Bruce Catton: A singular fact about modern war is that it

takes chargeDoing what has to be done to win, men perform acts that alter the very soil in which

societys roots are nourished. The average age in WWII was 26; however it was the 18-year-olds who

were put up front. Poet James Dickey said, Among the horribly wounded the most common cry was

mother!

During the Vietnam War was when PTSD came out of the psychological closet. The symbol of

the traumatized soldier was commonly depicted during the Vietnam War. American citizens

condemnation of the war was a significant environmental factor accounting for the veterans PTSD.

Vietnam was a total reversal of the zeitgeist as was evident during World War II. Before this time veterans

coming back from WWI and WWII were looked upon as heroes; Vietnam War veterans returning home

were seen as murders and were shunned and rejected by much of the community. This only traumatized

the returning soldiers more and exacerbated the PTSD.

Post-traumatic stress disorder (PTSD) is a mental health condition that's prompted by a terrifying

or severely distressing event that could be either experiencing or witnessing it. PTSD is marked by a re-

experiencing of the trauma: in thought, feelingwhich is in turn evidenced by emotional and

psychological numbing. Symptoms may include flashbacks, dreams and severe anxiety as well as

overpowering thoughts about the event. Post-traumatic stress really came to the forefront in the mid-60s

to the 70s due to the adjustment problems of numerous Vietnam vets. One Vietnam veteran said, You

cant take a 19-year-old brain and subject it to the constant threat of death or injuryand expect it not to

be affected. Robert J. Lifton a psychiatrist based at Yale University, said countless Vietnam vets

combined characteristics of the Traumatic Stress Syndrome (TSS) with an overwhelming

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preoccupation with questions of meaning... Psychiatrist Victor Frankel wrote in his book, Mans Search

for Meaning that an abnormal response to an abnormal situation is normal behavior. An interpretation

would be: if things dont make you crazy, then you arent very sane to begin with.

The Diagnostic and Statistical Manual: Mental Disorders (DSM-I) published in 1952 was the first

official manual of mental disorders. The use of the term reaction throughout the DSM-I mirrored the

influence of a psychobiological assessment that mental disorders epitomized responses of the personality

or character to psychological factors.

In the post-Vietnam period (mid 70s), it became obvious that many soldiers were in anguish,

suffering from severe psychological consequences as a result of their traumatic experience, yet

psychiatrists had no diagnosis to refer to in the DSM-II. In 1972, Chaim Shatan, a psychiatrist, wrote a

piece in the New York Times regarding the termed, Post-Vietnam syndrome. Soon afterward,

the Committee on Reactive Disorders was commissioned to search for whatever research on stress and

explore the possibility of adding the diagnosis to the DSM-III (Scott, 1990). The committee amassed

evidence from hundreds of cases for what was termed, catastrophic stress disorder. In the end, the APA

acknowledged the committees conclusions and properly reformed the term to posttraumatic stress

disorder (Scott, 1990). Shatans article in the New York Times reaped tremendous support for codifying

post-Vietnam syndrome in the DSM II (Scott, 1990). However, it wasnt until the 1980s that the term

post-traumatic stress. Fortunately, as our understanding of PTSD has changed or evolved since its

conception, so too has the treatment.

Much has changed since America involved itself in the Vietnam War. In 2001 America went to

war in Iraq/Afghanistan met with a new tactic of war; terrorism. Technological enhancements occurred

and the nature of war transformed so immeasurably that all things associated with war, including PTSD,

had to evolve. Yet even with new technological advances, PTSD lingers on being an extensive and

widespread condition of warfare. Combat in the mountains with an unidentified or unknown enemy has

had a tremendous impact on soldiers psychological welfare.

Terrorism has been the most haunting tactic seen in modern conflict. Civilians are not

theoretically to be targeted but due the fact that this is an unconventional war the enemy has to use every
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method of attack they can employ. This transformation in tactics, by both sides, inevitable meant a change

in how soldiers would experience combat and this change meant that PTSD would likewise change. Not

being able to define who the adversary was by just looking at his flag now it is almost impossible to tell if

the people by the side of the road are civilians or part of a military. As a result it led some down the road

of intense anguish. The exhaustive work by Kuehn shows that astoundingly it took a drastic or radical

upsurge in suicides among veterans for PTSD to amass the attention it required. It seemed as if the

product of Vietnam had washed-out. Lessons learned were lessons lost.

Soldiers are trained to kill with little regard of the enemy; to react instantly or lose your life. They

are conditioned consider the enemy as inhuman, but when they come close in confrontation to the enemy

that hypothesis is at times challenged. For example: You are outside on your way and suddenly you hear a

shot. You immediately fall to the ground for safety. You then locate the shooter. The shot rang from a

distance but you felt the wind as the bullet shushed by your head. You take aim. Slowly you prepare to

shoot. As the figure comes into your scope you slowly start to pull the trigger. Your heart is beating for

fear. The sweat is pouring off you. Your thoughts are racing. Then suddenly you pull the trigger fully back.

Through your scope you see the shooter fall from a two story building. Feeling somewhat relieved you

approach the fallen and suddenly notice it was a little girl about the same age as you daughter Candice.

With blood pouring from her head you just fall down and sit on the ground near her as tears roll down you

cheek and fall to the ground. You reach out to touch her almost as if to say youll be alright; Im here. You

immediately come back to your senses and realize you have just killed a little girl that did not know. Was

she forced to do what she did? Was she a victim of someone elses anger that forced her to confront you?

You pull out your wallet and slowly take the picture of your daughter out. They could have been play

mates. They could have been playing with dolls or having a tea party. How do we reconcile this morally?

Where do you go to rationalize her death away? It was her life or yours. This is where moral injury comes

into play. This is where you have a collision of right and wrong.

Moral injury is a philosophy that describes what many feel: a sense that their central

understanding of right and wrong has collided and been desecrated and damaged, misery, detachment or

guilt often follows. It is besieged with moral and ethical ambiguities of war. It suggests an injury to a

person's moral conscience ensuing from an act of moral offense which constructs profound emotional
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disgrace and shame.5 It is a disruption of the feeling of right and wrong that allows a wound to aggravate

the soul. Moral injury is a typical human reaction to an aberrant incident.6 Department of Veterans Affairs

psychiatrist Dr. Jonathan Shay says, Post-traumatic stress disorder is the primary injury, the

uncomplicated injury. Moral injury is the infection; its the hemorrhaging. Guilt, self-condemnation,

contempt of self and shame are at the epicenter of moral injury. Brett Litz, is currently a Professor in the

Department of Psychiatry at Boston University School of Medicine and the Psychology Department at

Boston University defines moral injury as perpetrating, failing to prevent, bearing witness to, or learning

about acts that transgress deeply held moral beliefs and expectation.7 It has also been depicted as act of

severe transgression that leads to somber inner conflict because the incident is at odds with core ethical

and moral beliefs is called moral injury.

Brett T Litz et al., Moral Injury and Moral Repair in War Veterans: a Preliminary Model and

Intervention Strategy. Although veterans make up only 7 percent of the U.S. population, they account for

a startling 20 percent of all suicides. Though treatment of post-traumatic stress disorder has

unquestionably assuaged suffering and allowed many veterans returning from combat to transition to

civilian life, for veterans under thirty the suicide rate has been escalating. It is no doubt that this moral

injury has also contributed with its engrained sense of transgression: feelings, grief, meaninglessness and

remorse from having dishonored central fundamental moral values and beliefs they held.

The cultural perception on moral injury has been fostered in Jonathan Shay work. He defines

moral injury as stemming from the betrayal of whats right by someone who holds power. 8 The

treatment of recovery should entail purification through the "communalization of trauma. Moral injury

5
Brett T Litz et al., Moral Injury and Moral Repair in War Veterans: a Preliminary Model and Intervention
Strategy, Clinical Psychology Review 29, no. 8 (December 2009): 695706,

6
Rita Nakashima and Gabriella Lettini, Soul Repair: Recovering from Moral Injury After War (Boston: Beacon
Press, 2012).

7
Brett T Litz et al., Moral Injury and Moral Repair in War Veterans: a Preliminary Model and Intervention
Strategy, Clinical Psychology Review 29, no. 8 (December 2009): 695706

8
Jonathan Shay, Odysseus in America: Combat Trauma and the Trials of Homecoming (Scribner, 2010).
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can only be forgiven when the trauma survivor [is] permitted and empowered to voice his or her

experience.9 For this to come about there needs to be sincerity on the part of civilians to not just hear

but to listen carefully what is not being said. The veterans experiences need to be accepted without

prejudgment. Fully coming home means integration into a culture or society where one is received,

valued, appreciated and respected, has a sense of place, purpose, and collective support. 10 It takes many

years for even the most sane among us to arrive at what we have seen and wanted to forget. When a

society sends people off to war, it must accept responsibility for returning them home to peace.

A Navy corpsman (medic) who served a tour each in Iraq and Afghanistan said, Guilt is the root

of it, asking yourself, why are you such a bad personI have a hard time dealing with the fact that Im not

me anymore. Dr. Shay says when an individuals moral horizon shrinks so does their ideals, principles,

values and beliefs. Its despair that rips people apart [who] feel theyve become irredeemable. Its a

colossal emotional and rational pain you live with. You dont feel that they can get past it because you feel

deserve it. It is morality at its best confronted with anxious mindset of self-preservation. Something very

devious has happened to you and corrupted your sense of self; you feel your life is without worth, the

universe is a vast depraved place. Moral injuries can also be caused by strikes to their moral stability,

ravaging their sense of right and wrong and often leaving them with an ongoing traumatic torment. This is

the moral concession made, having or forced to deliberately cast aside values, break something inside

yourself and transforming one into somebody hardly recognizable let alone acceptable.

A Marine squad of Charlie Company was pinned down in a gully, taking intense fire from an

adobe compound. Unable to move forward or to retreat, the squad leader OKd an attack and Lance Cpl.

Joseph Schiano, a 22-year-old on his second combat tour, lifted a rocket launcher to his shoulder, took

aim and fired. The blast blew apart much of the adobe building. As the dust settled, the Marines could

hear shouting and wailing. Their interpreter said, They want to bring out the wounded. As the torn and

bleeding bodies were dragged out, it became clear that the Taliban had herded women and children into

9
Ibid

10
Ibid
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the building as human shields. Another soldier told of a firefight in Iraq. Insurgents had suddenly rushed

toward him using women and children as shields. He had about three-quarters of a second to decide, and

of course he killed. When he arrived home, his wife handed him his new baby daughter. She put the

baby in his arms and he immediately gave the baby back to her with an almost disgusted look he almost

dropped her, he said. The thing was his new daughter was so beautiful and perfect and pure that he

didnt want his filth to contaminate her. This is the essence and depth of moral injury.

To speak to moral injury requires participating in moral questions regarding war with families,

communities and society. When such dialogues transpire, they mine a profound level of moral

questioning in which language moves from being narrative and descriptive to being immensely

transformative. A dialogue about moral injury targets morality, justice, and human dignity at the

epicenter of public attention and disclosures a collective amnesia about war and its victims. To listen to

the veterans that struggle with moral injury loosens the conversation from the individual issues of

veterans after the war to significant questions about the morality of war.
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References:

Andreasen, Nancy C. MD, PhD. (2011). What is post-traumatic stress disorder? Dialogues Clin Neurosci.

2011 September; 13(3): 240243. Retrieved from:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3182007/?tool=pmcentrez

Bentley, Steve A Short History of PTSD: From Thermopylae to Hue Soldiers Have Always Had A

Disturbing Reaction To War, Article Reprint Date, January 1991, March/April 2005

Bourke, Joanna. (2011). Shell Shock during World War I. BBC-History. Retrieved from

http://www.bbc.co.uk/history/worldwars/wwone/shellshock_01.shtml

Greenfield, Daniel P., Review of Madness, Malingering & Malfeasance: The Transformation of

Psychiatry and the Law in the Civil War Era, Journal of Psychiatry & Law 34, no. 4 (2006):

525530

Kuehn, B. (2009). Soldier Suicide Rates Continue to Rise: Military, Scientists Work to Stem Tide. The

Journal of American Medical Association, 301 (11): 1111-1113 doi: 10.1001/jama.2009.342

Scott, W. J. (1990). PTSD in DSM-III: A case in the politics of diagnosis and disease. Social Problems,

37(3), 294-310. Retrieved from http://www.jstor.org/stable/800744?seq=1

Smith, G. E., & Pear, T. H. (1918). Shell shock and its lessons. Manchester: University Press. Retrieved

from:

http://books.google.com/books?

id=zCQ6AAAAMAAJ&printsec=frontcover&dq=shell+shock&hl=en#v=onepage&q&f=fal

se
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Soldiers Heart - http://www.texvet.com/blogs/pjefferies/new-evidence-soldier-s-heart-ptsd-and-heart-

disease#sthash.wjnwTOh5.dpuf

Watson, P. (1978). War on the mind: the military uses and abuses of psychology. New York: Basic Books.