130226-M-IX060-006The United States Marine Corps Wounded Warrior Regiment provides and facilitates assistance to wounded, ill and injured Marines, sailors attached to or in support of Marine units, and their family members in order to assist them as they return to duty or transition to civilian life. (Photo by Cpl. Tyler L. Main)

“I really don’t like the term ‘PTSD,’” Department of Veterans Affairs psychiatrist Dr. Jonathan Shay told PBS’ “Religion & Ethics Newsweekly” in 2010. “He says the diagnostic definition of “post-traumatic stress disorder” is a fine description of certain instinctual survival skills that persist into everyday life after a person has been in mortal danger — but the definition doesn’t address the entirety of a person’s injury after the trauma of war. ”I view the persistence into civilian life after battle,” he says, “… as the simple or primary injury.”

Dr. Shay has his own name for the thing the clinical definition of PTSD leaves out. He calls it “moral injury” — and the term is catching on with both the VA and the Department of Defense.

We’re turning our attention to this idea of moral injury and the limits of the PTSD diagnosis to explore what happens to a person who has experienced combat.

There are no clean lines separating PTSD from moral injury (which is not a diagnosis) — there is no Venn Diagram, as with PTSD and traumatic brain injury – but Dr. Shay explains a fundamental difference by using a shrapnel wound as an analogy.

“Whether it breaks the bone or not,” he says, “that wound is the uncomplicated — or primary — injury. That doesn’t kill the soldier; what kills him are the complications — infection or hemorrhage.”

Post-traumatic stress disorder, Dr. Shay explains, is the primary injury, the “uncomplicated injury.” Moral injury is the infection; it’s the hemorrhaging.

PTSD in service members is often tied to being the target of an attack — or being close in relationship or proximity to that target.

Moral injury, Dr. Shay says, can happen when “there is a betrayal of what’s right by someone who holds legitimate authority in a high-stakes situation.”

That person who’s betraying “what’s right” could be a superior — or that person could be you. Maybe it’s that you killed somebody or were ordered to kill. Or maybe it was something tragic that you could have stopped, but didn’t. Guilt and shame are at the center of moral injury. And, as Dr. Shay describes it, so is a shrinking of what he calls “the moral and social horizon.” When a person’s moral horizon shrinks, he says, so do a person’s ideals and attachments and ambitions.

I first came across Dr. Shay’s name — and his concept of moral injury in combat veterans — in a heart-smashing profile of Noah Pierce published by the formidable Virginia Quarterly Review.

The Life and Lonely Death of Noah PierceThe Life and Lonely Death of Noah Pierce” tells the story of an Iraq War veteran from Sparta, Minnesota, who shot himself in the head in 2007 at the age of 23.

From Ashley Gilbertson’s profile of Pierce:

“When Noah went missing in July 2007, after a harrowing year adjusting to home following two tours in Iraq, police ordered a countywide search. His friend Ryan Nelson thought he might know where to look. When he pulled up to the spot, he immediately recognized Noah’s truck. Inside, Ryan found his friend slumped over the bench seat, his head blown apart, the gun in his right hand. Half a bottle of Jack Daniel’s Special Blend lay on the passenger seat, and beer cans were strewn about. On the dash lay his photo IDs; he had stabbed each photo through the face. And on the floorboard was the scrawled, rambling suicide note. It was his final attempt to explain the horrors he had seen–and committed.”

Gilbertson told Noah’s story to Jonathan Shay. Again, from the article:

“Shay, a psychiatrist who has worked with combat vets for twenty years and authored two books about PTSD — or psychological and moral injury, as he insists it should be known — told me by phone from his Newton, Mass., office, ‘It’s titanic pain that these men live with. They don’t feel that they can get that across, in part because they feel they deserve it, and in part because they don’t feel people will understand it.’

“‘Despair, this word that’s so hard to get our arms around,’ he said. ‘It’s despair that rips people apart [who] feel they’ve become irredeemable.’

“I told Dr. Shay about Noah’s experiences in Iraq, in particular the killing, the loss of comrades, the nightmares. He sounded saddened on the phone, but unsurprised. ‘The flip side of this fellow’s despair was the murderous rages he experienced on his second tour,’ he said. ‘In combat, soldiers become each other’s mothers. The rage, need for revenge, and self-sacrificial commitment toward protecting each other when comrades are killed [are] akin to when a mother’s offspring are put in danger or killed.’

“Dr. Shay explained the nightmares and sleeplessness were one of the major issues. ‘The lack of sleep contributed directly to a loss of control of his own anger, a loss of control of things he felt morally responsible for.’”

Treating moral injury in combat veterans, Dr. Shay said in the PBS interview, happens not in the clinic, but in the community.

“Peers are the key to recovery — I can’t emphasize that enough,” he said. “Credentialed mental health professionals like me have no place in center stage. It’s the veterans themselves, healing each other, that belong at center stage. We are stagehands — get the lights on, sweep out the gum wrappers, count the chairs, make sure it’s a safe and warm enough place…”

He doesn’t write off clinical care, though he does disparage “cookie-cutter treatments.”

“We’re certainly doing a lot of things,” he says, “but whether we’re actually preserving vets’ capacity to have a flourishing life after war, I don’t know. I just don’t know.”


Jeff Severns Guntzel is senior reporter for the Public Insight Network (PIN). He has reported from the Middle East and points all over the United States for a cadre of publications and news organizations that are not usually mentioned in the same sentence, including Punk Planet Magazine, National Catholic Reporter, Village Voice Media, MinnPost.com, and GOOD. He also did time as an editor at Utne Reader.

Read more of Jeff's reporting as part of the Public Insight Network's veterans health project on vets and all those working to help them navigate life after combat.

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14Reflections

Reflections

Thank you for this. We may finally be on to the truth. The psyche cannot absorb the "dogs of war." And each person affected passes this one to at least 4 generations. War truly is H*ll.

The impact of war on human beings always opens the door to examine broader human experiences. Using wartime research on PTSD, it became clear that adversarial and predatory behaviors also cause complex PTSD in legal proceedings, corporate schemes to trick consumers and so it is with moral injury. In legal cases that have been filled with trickery and violations of all a person holds dear for years on end in wars of attrition also meet the criteria for moral injury. Human beings need some simple things and holding to a moral code is one of those critical staples of a civilized society.

DR Shay has got it right. Shame and guilt are killers.............. and its not just killing or surviving behavior for which veterans feel shame or guilt....

I'm very moved by this piece for several reasons and will try to be brief and to the point. I am interested in this topic because I am a veteran, too Not a veteran of any foreign war, nor veteran of any national military branch; I am a veteran of the 'war at home,' and that war has left me with the diagnosis and effects of PTSD - just as devastating and debilitating as many of our military veterans. I do not wish to draw attention away from the plight discussed in this article - it is too real and too painful and too destructive to dismiss. I also do not want to disparage any further research, treatment progress, discoveries that have come from the veterans' diagnoses and ground-breaking work that has flourished amidst such pain because it is through the identification of the symptoms of PTSD by veterans that those of us were finally able to be recognized as suffering similarly

The 'war at home' I speak of is domestic violence - multi-generational, repetitive, unrelenting - and it is something that carries the primary injury past the first offense and collateralizes the damage to the very apt description of 'moral injury' as so eloquently stated by Dr. Shay, I know my own experience has been the identified result of two generations before me of domestic violence brought into both my parents homes and then brought into my home as a child The third generation of domestic violence came into my adult home with my three children in the guise of two men - one their father, and the second their stepfather - as well as the continued abuse from my parents and their grandparents.

When I read the descriptions of the 'mothering' that is often required of the soldiers in combat, I was reminded of how my brother and I 'mothered' each other through the years of abuse; how my children 'mothered' me and themselves during our years of abuse and how the last thing we know how to do even now is 'mother' ourselves. I watch the subtleties of these atrocities continue to visit myself and the lives of my children. I know we are the 'walking wounded' who are making it look pretty good on the outside and not doing very well at all on the inside. We can talk about it, but would prefer not to; our friends and family give us space and time, but also wonder when we'll 'get over it.' Hell, even we wonder when we'll 'get over it.' too.

I am seeing a wonderful therapist and we are making more progress than I have been able to do before and still, I am stunned to hear her describe the work that is still ahead of us to 'put me back together again,' I am still not completely aware of the damage that has been done. I'm so used to being damaged that I don't know there is damage visible to a trained eye. I want to be whole and integrated; I want to live a full, vibrant life; and I want that for my children and for their children

Dr. Shay diagnoses effective treatment as being done with peers. I wholeheartedly endorse that form of treatment. I was in a support group for battered women and children over 10 years ago. Sadly, the abuse had barely begun with the last perpetrator - I had not even identified it as abuse at the time. I was attending the group to become an advocate of support for other women and their children. Sadly also, the group as so many like it, were disbanded due to budget cutting by the hospital that supported the advocate who founded the group.

I am grateful that the veterans have the funding and available support for them and know how difficult it is for many of them to access the help they desperately need and want. Because of the shame and blame that is part and parcel of this diagnosis, those who want and need help rarely reach out for it. The same is true of us veterans of the war at home; perhaps, even more so. We are told by so many people -- family, friends, police, court personnel, lawmakers, even the law breakers - that we are making too much of this, that it's 'over' and we should just 'move on' with our lives. We are told to 'honor our fathers and mothers,' 'honor our husbands til death do us part;' we are crippled further by the short-sighted and short-handed judicial system; we are hobbled by a society that still frowns on a woman who leaves her husband, regardless of how legitimate her reasons may be, we are forced to advocate for ourselves when our self has been battered and bruised and humiliated into a place where we never believed love would send us and where we barely know how we survived much less how we will do it.

I tell people who want to fully understand what I would consider fair and equitable treatment of us veterans of the 'war at home' that justice will be when the perpetrators of domestic violence are treated as rightly by society and the justice system as if they were any other criminal who would invade our homes and our lives and cause us harm. A stranger is held to a higher standard of justice than our fathers, husbands, parents; somehow, because it is a 'domestic' issue, it counts for less than if it were not. The same can be said for military veterans - we other veterans get the fallout from their treatment and I am glad for it - I just wish neither of us had to go through what we have gone through and continue to go through because of the 'moral injury' that has taken place.

My last point is this - at best, moral injuries are difficult to treat. How do we know when we are 'well?' How does one know when the moral injury has been 'healed?' we are a society that attends to things we can measure, quantify, judge complete. This 'moral injury' premise will take a long and large leap of faith to be embraced - my hope is that it will be sooner rather than later. Keep me posted, please, I am interested. Rhonda @ onceagain2007@gmail.com

I'm a survivor of rape and I can tell that what you say is 100% truth. Thank you Rhonda

wow rhonda, you hit the nail on the head. as a victim of DV myself, i tried so many times to let my marine boyfriend (well ex now) know that i can relate to what he is going through. he never believed that, this i know. yeah, being in a warzone with guns and killing is certainly different, however, when you live in fear daily of beatings, verbally, mentally, as well as physically, it wears you down. i have done a lot of work myself to try to nip this in the bud. i just recently started talking to my mother, which i am still shaky about, because she has no recollection of what she put me through when i was growing up, and my younger sister would always tell me that i was bitter and i needed to get over it. its not how it works. she was safe from all of that abuse, she was actually the one that perpetrated a lot of it thru my parents. i was in a DV shelter for 4.5 months, and oh man, i never thought that i would EVER be in that situation, but there i was. i met a lot of ladies who were in there because of significant others, and i was the only one that was there because of my parents. but, the more talking i did, and the more people i tried to help (which was mostly the kids, because i knew exactly how they felt in their situation) the more i helped myself. the therapy was great as well. i went to as many groups as i could throughout the week, because i was there for a purpose, not just a free place to stay because i had no where else to go. it only helps if you think that it will, and i did. my gram keeps telling me that i need to mend fences with my parents, but i cannot give them chance after chance to repeat the same behaviors over and over again like i had in the past. i feel that i am a very moral person, considering what i have went thru in my life. i could very well be another statistic, but i choose to refuse to do so. it is a hard road, but anything worth doing isnt going to be easy...this i know. its a work in progress that i still encounter daily challenges with.

I was diagnosed with PTSD due to DV. Your words "being in a warzone with guns and killing is certainly different, however, when you live in fear daily of beatings, verbally, mentally, as well as physically, it wears you down." was a eureka moment for me. As I mentioned in a reply to Rhonda I grappled with guilt over how I could have experienced the same level of stress as a war veteran, but your words validate my pain. As to talking to, in this case, my mother about her actions, it was a challenge. My expectations of any regrets expressed by her was short lived when she responded to my why's by saying "you were a difficult child". I wanted to shout "Yes, I was a child...and you were supposed to be an adult!", but had to let the moment slip by. Whether time or denial was the cause she did not want to deal with it. While I am thankful that I was self aware enough to not repeat the actions of my mother on my children, I sadly wonder what inner demons made her lose control to that degree. I have learned to let go of my why's and move forward.

Thank you for your well written thoughts. When I was diagnosed with PTSD my first thought was "This is a condition of veterans of war" and I've grappled with guilt over how I could have experienced something as damaging as they had....surely I am making a mountain over a molehill. Your words struck a chord and it helps to know that there are others out there whose DV experiences caused PTSD. It helps lessen the guilt.

We believe Dr. Shay is onto something in raising awareness in Moral Injury, but we think he has the causal relationship backwards. In Dr. Shay's model, "something happens to you," and that makes you feel you or life is without worth, the universe is an immoral place, etc. Based on our research with US Marines (TECOM Resilience Research Project), and an agentic theory of human beings, we understand it to be the reverse. Marines can narrate how they make moral judgements about themselves as leaders, parents, spouses, etc. and then because of their decision, develop attendant complications. In the first model, military members are passive subjects, affected by forces/circumstances; in the second model members are agents, actively trying to navigate the complex contexts of their lives.

This is a meaningful difference. If self-judgments in the wider context of living (or which moral injury in response to the battlefield is a subset) is the star--if the members are the causal agents, how we help prepare--support and assist them as they make meaning of their lives, is very different than what we shoudl do if members are passive victims of events.

When I trained at the VA in chaplaincy I experienced this in my hospice veterans. Their moral injuries poured out as their normal life reflection process unraveled. As theirs did, my deceased dad, WWII secret of "friendly fire" where he mistakenly was told to kill his own soldier by his commander who did not like the soldier to be killed leaked out of my dad's memories in disconnected ways. I knew he would never link the truth for me because he was loyal to his military pledge as a sergeant Dad began electric shock treatments after the death of his mom. Each death of a family member as dad aged required more shock. In all he had over 150 shock treatments. His good psychiatrist told me towards the end of his life, "this good man is not getting relief from the shock treatments anymore. Something in his moral life wants to come up and out as he nears his death. For me and my brother we too had felt the effects of my dads moral injuries. My dad's brother recently told me that all his family on the farm were terrified as my dad dressed in his uniform at night and shot his gun off as he patrolled the yard, re enacting the event over and over. We have moral injuries from all of his untreated war experiences. Most Veterans never qualify for help because of their income. So as the chaplain at the VA helped me understand how these Vets go through their moral injuries he pointed out to me that my brother and I and the whole family carry PTSD and the moral injuries our dad inflicted on us by his rage, beatings, and fearful behaviors. Your moral injury explanation is on target and I will be using your description of it in my chaplaincy profession. Thank you

I have been blessed by a great counselor, Patsy F, with the VA. When the concept of moral injury was explained as above, it was as if a switch had been thrown. Finally, a clear understanding and explanation of what I had been going through. I deeply appreciate those who have researched and finally clearly explained what so many have been suffering.
I know now that I did the best that I could, but I failed to protect the innocent none the less. I have lived with guilt and severe anxiety. I have not yet come to grips with it fully, but just knowing and understanding the concept has allowed me to begin to heal. The best I can describe it is that the anxiety feels like the lash of an icy, satanic whip. I had no peace and guilt always pointed a finger at my soul. Moral injury is that bad. The aftermath was worse than the war. Being able to understand the concept of moral injury has allowed me to move forward and out of the pit. Thank you to all who to help vets. you are saving lives.

Thank you JIm for sharing hope for many Veterans and Caregivers that are reading this message.
I agree with you it is a process, one day at a time. Many Blessing to you.
God Bless America.

Oh, Dr. Shay has it right. Problem is, the power structure, be it, a military command or the VA Mental Health, still keep the veteran in his place when it comes to PTSD. Here in Pittsburgh I was being given 60-65 GAF scores while I was being charged with felony assault charges at work where I carried a gun. I was a federal police officer. My own private health care were gining me 35 GAF scores at the same time. I did beat the charges since there were no witnesses and the alleged attack was a week after I got out the hospital for bleeding in the head. At the time I had a 30% PTSD rating.
Since then I was awake in the middle of the night because I couldnt sleep. I had my Glock automatic on my lap and was watching TV. Finally around 4AM I fell asleep and then not long after that I was dreaming about VN. I dont know how it happened but I pulled the trigger and shot myself. Almost killed myself, broke the femur, hit the artery.
I am a survivor of Hill 875 and was at the CP when the Marine Corp F4 Phanton dropped two 500 pound bombs on it. Thank GOD one was a dud. The 173d and 4th Infantry command knew we were well outnumbered when they sent us (330 of the 2d Battalion 503d Infantry, 173d Airborne) up the Hill. The total was around 158 dead and a lot more wounded. A lot more the protected dont care about. They think giving 10% is being generous. More wounds back home. Your sacrifice doesnt matter. Im on the Hill every day. Have been since 1967. Its really a shit place.

Thank you for this clear description of what persons recovering from trauma suffer.

apples