Peter Van Buren on Moral Injury and Hooper’s War

As research for Hooper’s War: A Novel of WWII Japan I encountered people suffering in ways they had a hard time describing but which they wrestled with God over everyday. They told me they went away to fight with an idea “we’re the good guys, they’re not” that did not always survive the test of events. They spoke of a depth of pain that needed an end, some end, and for too many, as many as 22 a day every day, any end, even suicide.

That’s to scratch at describing what we now know as moral injury. The term is fairly new, especially outside of military circles, but the idea is as old as war — each person sent into conflict finds their sense of right and wrong tested. When they see something, do something, or fail to do something, a transgressive act, that violates their most deeply held convictions, they suffer an injury to the soul, the heart, their core. There are lines inside us which cannot be crossed except at great price — ignoring a plea for medical help, shooting a child in error, watching friends die in a war you have come to question, failing to report a sexual assault witnessed, a sense of guilt simply by presence (documented well in Tim O’Brien’s iconic Vietnam War book, The Things They Carried), can cause moral injury. Moral injury is represented well in documentaries such as Almost Sunrise, and though not by name, in films like William Wyler’s 1946 The Best Years of Our Lives and Oliver Stone’s 1986 Platoon.

Society once expressed skepticism toward such ideas; well, perhaps not skepticism, for that implies more of an open mind than calling sufferers cowards, or dismissing them by saying it’s all in their heads, have a drink, take some time off. Now sister illnesses to moral injury such as Post Traumatic Stress Disorder (PTSD) are not only acknowledged as real, but new MRI technology can pinpoint their effects inside the brain.

Moral injury differs from PTSD in that it is tied to the parts of a person that decide right and wrong, and applies guilt, regret or shame as a penalty. PTSD is fear-based, and includes stresses like hyperalertness that worked well over there in war (quite valid adaptations in the mind and body, such as hitting the ground when hearing loud noises, to the real situation of other people trying to kill you), but are dangerous, exhausting, and frightening back here. The flight-or-fight response just won’t shut off, even in the absence of threat. PTSD to many is a loss of safety, but not a loss of self. Moral injury might be thought of as a disconnect between one’s prewar self and a second self develops in the face of death, action, or inaction. Moral injury jumbles these two selves which cannot in fact live well together inside one body.

There is a formal definition of moral injury, “the lasting psychological, biological, spiritual, behavioral and social impact of perpetuating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” Moral injury occurs at the intersection of psychology and spirituality, and so, in a sense, is all in someone’s head — as we are thinking beings with a complex sense of right and wrong, then it follows that sense can be broken. Moral injury ironically represents a strength of character — as a human being they cannot ignore what was done — but it feels like a weakness.

The term moral injury may have originated with Jonathan Shay, a psychiatrist who conducted groundbreaking work in PTSD, publishing two books, Achilles in Vietnam: Combat Trauma and the Undoing of Character and Odysseus in America: Combat Trauma and Trials of Homecoming, examining the experience of combat through classical texts. Others place the origins of the term moral illness with Vietnam veteran and philosopher Camillo Mac Bica.

The Department of Veteran’s Affairs now acknowledges moral injury and its effects. Syracuse University created the Moral Injury Project in 2014 to bring together veterans, doctors, chaplains, and mental health providers. Psychologists are developing diagnostic assessment tools.

Because the research on moral injury is in its infancy, there are no data yet on the number of combat veterans who suffer from it. But the conditions of modern warfare, from Vietnam forward, suggest they are many.

“There are no long front-lines,” said Nancy Sherman, a philosophy professor at Georgetown University and author of Afterwar: Healing the Moral Wounds of Our Soldiers. “The city or village is the war zone today. Women and children are armed. Men are fighting without uniforms.”

But that sounds too clean to me. Because the results of those two words — moral injury — are exactly what you might expect: a long-war struggle for understanding, thoughts of suicide, and self-medication.

I came to know a handful of veterans, and spoke intimately with the men and women I lived alongside in Iraq for a terrible year that was scarred by two soldier suicides. I spent time speaking with Japanese who lived through WWII as civilians. One now-elderly woman remembered her mother’s own moral injury after seven decades, a failure to comfort two dying siblings, hearing her mother’s ghost say in a park in 2016 Tokyo “Haruo-kun, that day of the firebombing was so hot for you. Akiko-chan, you wished so hard for water then. Please drink now.”

What response can there be to something so human?

A lot of pain festers not just out of what people saw, as with the Japanese woman, but the realization that what they saw and did really didn’t matter in any bigger picture. It should’ve had a reason, many pleaded to me. People say to sufferers, “whatever you have to tell yourself,” to help them create justification, but they forget you can’t lie to yourself alone at night. Imagine what it’s like to be in your 30s, or 70s, and scared of the dark. Imagine you have real reasons to be scared. Imagine you want to cry years out of you. Imagine failing to understand what you feel, not being able to talk much about the things you think about every day.

Suicide is never far from moral injury. The soul isn’t that big a place.

It is above all the act of killing that does it: 70 percent of those Afghan and Iraq veterans who participated in heavy combat attempt suicide. One guy who told me he has never forgiven his neighbor from talking him out of going into the garage with his rifle. Another who said the question wasn’t why he might commit suicide, but why he hadn’t already done so. The Department of Veteran Affairs counts 20 veteran suicides a day. About 65 percent of all veteran suicides are by individuals fifty years and older who have had little or no exposure to the most recent conflicts.

A lot of those suffering from moral injury self-medicate. Seeking help is still a stigma for some, the hard work of recovery too hard or too slow for others.

Drinking (drugs for many of the younger guys) hurts. Everyone learns it just sends pain off to wait, but still it was something to look forward to, they told me, the first fizzy beer of the day tickling their nose, or the throat-burning shot of something stronger biting into an ulcer. Drinking wiped away hours when someone had too many of them, all the way back to 1945 sometimes. You drink in the dark places, a bar, an unlit living room because there is a sense that you have lost your future and that’s easier to deal with when you can’t see anything (you see too much in the dark anyway.) Pain can be patient, a drop of water swelling on the end of a faucet, waiting for that one guy who had a little too much at a wedding and started talking about blood and brains in some alcoholic dialect until a couple of other vets walk him outside where he tells stories from his knees which they understood.

The trip back is as complex as the individual, and the most effective treatments evolving. “Soul repair” is the term some use.

One path to healing is via helping a patient to understand (“owning it”) what happened and their own responsibility, not necessarily fault, for transgressions. Others speak of seeking self-forgiveness, including a benevolent moral authority, often because those transgressed against are dead.

Another way back is for the sufferer to make amends, either toward those harmed, or to a third party. To amend literally mean to change something already done, and in the case of moral injury that is drawing a line between who one was then and can be now.

The goal is to accept wrong was done but to also understand it and learn how to deal with it; the act, while impossible to reconcile or forgive, does not have to define the rest of a life. The goal is for individuals to reclaim good parts of themselves and to examine and accept — but not be defined by — what they did, what they saw, what others did,

What doesn’t work, in the eyes of one veteran-advocate, Matthew Hoh, is lying, as we do every day in the United States, telling veterans who view themselves as villains they are really all heroes. Hoh, after leaving the Marine Corps after service in Iraq and Afghanistan, later became one of only four State Department officials to resign in protest over the post-9/11 wars.

“You mean like that Vietnam helicopter thing?” a well-meaning family doctor asked me when I told him coming home from the anemic role I played in Iraq left me more interested in vodka than my family, with a few too many orange containers lined up next to the sink even before I saw him. That was my own tiny taste of this, a failure to have accomplished anything, but I was lucky to benefit from some good people who helped me to accept my choices, and give up trying to erase them or explain them away. I didn’t want pity or understanding, I just wanted to get this stuff out of my head.

The process is hard; it doesn’t always have the happy ending I wrote into my story. Sometimes these things don’t end when the war ends. Sometimes for some men and women they don’t end until they do. That’s the end loss for everyone.

Peter Van Buren blew the whistle on State Department waste and mismanagement during Iraqi reconstruction in his first book, We Meant Well: How I Helped Lose the Battle for the Hearts and Minds of the Iraqi People. His latest book is Hooper’s War: A Novel of WWII Japan. Reprinted from the his blog with permission.