Moral Injury in Returning Veterans: You'll Hate Me If I Tell You

How can clinicians help veterans with PTSD deal with depression and anxiety symptoms, and process intense feelings of shame and guilt stemming from actions and situations they experienced while serving?

Day in and day out for years and sometimes decades, soldiers respectfully acknowledge their commander, “Sir, yes, Sir!” Many perform their duties admirably, but some break the rules of war.

As the Toledo Blade reported, in Viet Nam for example, a platoon known as Tiger Force in the US Army intentionally blew up women and children in underground bunkers, and committed a variety of other war crimes, leaving too many dead unnecessarily.

Running on little sleep for long periods of time makes it hard for soldiers to make good moral judgments, especially when fellow soldiers bully them when they show any amount of emotion in response to killing, whether it is justified or not. If it’s not, they hurt themselves.

As a result, Jonathan Shay introduced the term “moral injury.” That is, when there is a betrayal of what’s right by someone who holds legitimate authority (or self) in a high-stakes situation.

Currently, this is not a diagnosis; it’s more of an existential state. Moral injury is only used to describe extreme cases of atrocities, and these soldiers often also have post-traumatic stress disorder (PTSD).

Post-traumatic stress disorder and traumatic brain injury are the signature mental illnesses afflicting veterans of wars in Iraq and Afghanistan. But advances in the treatment of trauma have led to the conceptualization of moral injury as a state distinguished from PTSD.

No soldier experiences moral injury unless he has an intact conscience. So this is not the case of a soldier being a sociopath. There’s this dissonance and conflict, and the patient thinks, “This is not who I am! I don’t go into villages! I don’t burn children and I don’t shoot at people! This person never did anything to me!”

Some experience guilt and others experience shame, but almost all feel anxiety. What’s the difference? When a person feels guilty, they feel as though they are responsible for something and maybe there’s something they can do. When someone experiences shame, it’s on a deeper level. They think that there’s something wrong with them and that they deserve condemnation, punishment, and in many cases, not to live.

In Indianapolis at the American Psychiatric Nurses Association (APNA) 28th Annual Conference, October 22-25, 2014, Doris C. Vallone, PhD, PMHCNS-BC, Clinical Nurse Specialist, Philadelphia VA Medical Center, Philadelphia, PA, wondered how many suicides are related. She said no one knows for sure.

According to Vallone, patients who are experiencing this think “I can’t live with myself any longer that I have done this! And I can’t even speak the words to another human being because I feel so horrible about myself. I am a bad person! I am not worth living! I did this horrible, horrible thing.” The shame and the feelings it evokes become internalized.

The guilt, shame, and anxiety cause a profound withdrawal. There’s isolation in PTSD, but this is different. Families are destroyed. “I just stay in my room, smoke my cigarettes, drink my alcohol and this is my prison,” one patient said to Vallone. “So it’s kind of like a self-prison. ‘I should be in prison, so I’m going to create a prison for myself.’ And I’ve had it described like that,” said Vallone.

Among these patients. there’s a complete failure to forgive oneself, and complete condemnation (“I am a worthless human being!”). But the more patients avoid, the more it shows up. And the outcome is dangerous behavior, often not caring if they live or die.

How to assist patients in processing these feelings? Help your patient connect with the person in front of him. Prolonged exposure with a therapist to take the shame out of the story, and then reframing it can help. Ask them, “What good came out of your trauma?” Corrective responses help as well; for example, donating or volunteering for a charity. And forgiveness, which takes time, but makes it possible for the patient to realize they did a horrible thing, but now they can move on and get past it.