PTSD and Moral Injury as the Consequences of War Trauma

Consequences of War Trauma

One of the possible consequences of war trauma is the de-

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velopment of post-traumatic stress disorder (PTSD). PTSD is a neurobiological and hormonal imbalance. Unfortunately, untreated PTSD will almost always become worse and one response may be to self-medicate through alcohol and street drugs. Furthermore, PTSD from combat often has co-morbidities including: depression, suicidality, interpersonal difficulties, and reactions of rage. Soldiers in war may become well acquainted with death and atrocity, which is hard to leave on the battlefield.

Robert J. Lifton described the intense intrusion of the reality of death into the mind of young veterans as “death’s imprint” (“Understanding the Traumatized Self: Imagery, Symbolization, and Transformation,” Human Adaptation to Extreme Stress: From the Holocaust to Vietnam, 1988). He clarified that it could be extremely challenging for young soldiers to assimilate what they saw and experienced. Lifton put forth that outside of combat, men and women are unlikely to face their mortality in such a brutal way. Living in a space where one alternates between the fear of being attacked and an uncompromising readiness to destroy another speaks to the heart of war and the shadowy side of humanity.

Reviewing the research reveals that there are two military populations that are at high risk for developing PTSD. One group being those who are traumatized by the severity of combat and are considered victims, and a second group being those who participated in activities that they saw as immoral, such as the atrocity of killing innocent people and torturing or executing captives. These veterans are at risk to develop psychiatric symptoms including depression, suicidality, PTSD, and moral injury.

Syndrome of “entering a bombed village”

Before troops enter a village that they assume is enemy territory, their artillery unit may bomb the village from a distance. Afterwards troops enter the enemy territory for occupation. They are exposed to the numerous injuries/deaths of civilians, which their own unit had caused. Because of this, some troops develop feelings of guilt, shame, and devastation. Nightmares disturb them at night. Flashbacks trouble them during the day. As one soldier reported, “I have repeated nightmares of dead Iraqi children chasing me, calling me a murderer.” This was a soldier who had volunteered to go to war with the desire to become a “freedom fighter.”

Moral Injury and PTSD

Looking at the research articles, it is clear that moral injury

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differs from PTSD. Moral injury may not have a specific traumatic event that precedes it. Additionally, PTSD is a medical diagnosis and the only major psychiatric disorder with a known etiology. Moral injury generally has “a slow burn quality.” To be morally injured one should have a stable brain that can experience empathy and sympathy, create a coherent memory narrative, and be able to comprehend ethical and moral reasoning (Rita Nakashima Brock, “Moral Injury: The Crucial Missing Piece in Understanding Soldier Suicides,” The Huffington Post, 2012). The veteran who suffers from moral injury will feel shame, guilt, sorrow, regret, grief, and/or a change in self-image—no longer feeling innocent or like a hero, but, as one of them reported, rather like a monster or criminal. Recent research conducted on approximately 900 National Guard troops revealed that experiencing both moral injury and PTSD increases the risk for suicidal thoughts and actions (Craig J. Bryan, AnnaBelle Odette Bryan, Erika M. Roberge, & Feea R. Leifker, “Moral injury, posttraumatic stress disorder, and suicidal behavior among National Guard personnel,” Psychological Trauma, Research, Practice and Policy, 10[1], 2018).

Definition of a Hero: One Who May Not Develop Moral Injury?

A combat veteran described one experience in Iraq with his sergeant. They were chasing a suspected enemy through the streets of Baghdad. The suspect was driving fast but eventually came to a roadblock and had to stop. His sergeant took his gun and went over to the car, ordering the suspect out. The sergeant then discovered this was just a regular civilian and he let him go. The sergeant’s behavior went against military recommendations that the Army taught, as this suspect could have been carrying a bomb, and at times, one may need to shoot first and ask questions later. Yet this sergeant’s actions could be seen as heroic, to put himself at risk, rather than harm an innocent person. Additionally, he prioritized his moral guidelines over military instructions. His actions were in alignment with his beliefs about what was right and therefore would not cause moral injury (Jamshid Marvasti and Anton Power, “Veteran Suicide, War Trauma and Moral Injury,” American Journal of Forensic Psychology, 34[3], 2016).

Drone Warriors and Moral Injury

The use of drones has opened up another source of moral injury. Eyal Press researched and published an extensive piece on this topic in the New York Times Magazine (“The Wounds of the

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Drone Warrior,” June 13, 2018). Drone operators, while not on the ground, are still greatly impacted by the consequences of their actions in war. There has been concern that using drones in warfare creates the illusion that terrorism can be fought by pushing a button, and that those who have this role may act as “‘joystick warriors,’” disconnected from war’s moral gravity. However, research conducted at an Air Force base in Ohio showed that 75% of the 141 analysts and officers involved in remote combat experienced grief and remorse (Press, “Wounds”). Additionally, these drone operators are exposed to greater graphic violence than most forces on the ground.

Given that these drone pilots are not in the field, where we’d typically expect them to be exposed to direct physical and emotional trauma, it may be easy to overlook the emotional and psychic strain that they experience from viewing these graphic images daily. However, it is pervasive and crippling, as evidenced by the high rate of burnout.

Drone Pilot Life and Statement

One previous drone operator shared of a strike execution that left the “terrorist” dead, but spared his child who had been walking next to him. The operator then saw a horrific scene, as the child went to pick up the pieces of his father to try and put him back together.

These pilots experience an intense back and forth transition, going from dropping missiles on the enemy, to 20 minutes later picking up milk on their way home to see their family. Some drone operators feel they are making a difference with the work they do, but they may still struggle with stress, suicide, divorce, and inner conflicts around what they do—namely, “moral injury.” They are consistently viewing horrifying images, often based on their actions or when they failed to act. One study at Langley Air Force Base reported that overall, their personnel had pride in their missions; however, they also struggled with distress and interactions with their family and friends, emotional numbness, and trouble sleeping due to disturbing images (Press, “Wounds”).

One drone operator shared that the computer feed clarity could vary. On a good day, when all the environmental and technological factors came together, it was more clear who they were looking at. However, other times it was a grainy image and therefore hard to distinguish a civilian with a walking stick from an in-

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surgent with a gun. Those days, one had to guess.

Frequency of Drone Attacks

While drones have become an essential piece in warfare, information about them is covered in secrecy, with the public not having much of a sense of how, when, or with what consequences they’re being used. Non-governmental organizations (NGO’s) and independent monitors have reported that the U.S. acknowledges a much lower number of strikes and civilian causalities than its own reports. Since 2010, U.S. drone strikes have killed between 8,000-10,000 people with around 750-1,500 being civilians in Pakistan, Afghanistan, Yemen, and Somalia, according to the Bureau of Investigative Journalism in London. The U.S. government claims instead only 64-116 civilians were killed by drones between 2009 to 2016.

Drone operations, nicknamed “kill chain,” expanded greatly under President Obama. During his presidency, he authorized around 500 drone attacks outside of active conflict areas, which was 10 times more than President George W. Bush. This is not including drone strikes in Iraq, Afghanistan, and Syria (active conflict areas). President Trump has further expanded drone operations, authorizing five times the number of strikes in his first seven months than President Obama had in his last six months in office (Press, “Wounds”).

Impact of Killing

Shira Maguen, a researcher and psychologist with the VA (Veterans Administration), found the distress soldiers experienced was less about surviving attacks by the enemy and was more connected to their actions that may have crossed their internal ethical boundaries. One soldier relayed that he thought he was doing the right thing, killing a car full of enemies, but later found out there was only a family inside. In her research, Maguen found that regardless of different experiences in combat, “killing was a, ‘significant, independent predictor of multiple mental health symptoms’” and social impairment. One Army chaplain who served in Afghanistan eventually resigned as a military officer. In his resignation letter to President Obama he shared that, “he could not support a policy of ‘unaccountable killing,’ that granted the executive branch the right to ‘kill anyone, anywhere on earth, at any time, for secret reasons’” (Press, “Wounds”).

Moral Injury: Not Accepted as Diagnosis

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While research suggests moral injury is a widespread experience, it is still contested in the military and psychological community (Jamshid Marvasti, “Moral Injury and suicide among warriors,” Clinical Psychiatry News, June 2014). It is a threatening idea to the military that war could cause moral injury because it may put soldiers in a position where they must do something that they feel is wrong. One drone operator shared that the images he saw on the screen could be so hard to read that he could not tell if something was a chicken or a child. He also relayed the pressures he felt by his superiors to be certain of things he could not be, such as verifying if there was anyone else besides a Taliban commander in a compound. Sometimes he would just say “no” because he knew they did not want to hear “I don’t know” (Press, “Wounds”). In the Vietnam War, some veterans reported that they were told to count any dead body as Vietcong, including children and even animals, like monkeys.

Moral Injury and Drone Operators

Additionally with drone warfare, operators may “get to know” their target more so than someone in the field. They may watch their movement for days or weeks, seeing them buy food at a market or play with their children. Then the risk of moral injury may be greater because even if they are the enemy, the drone operator has seen their humanness as well. Enemies considered nonhuman may allow soldiers to more easily physically and emotionally kill them.

One drone pilot shared that one of the hardest challenges in recovering from doing this type of work was acknowledging that a part of him enjoyed this power to take life and the excitement that came from it. Yet along with this feeling was a sense of shame and grief. Furthermore, while in the beginning he had felt connected to his missions, over time, he saw them as short successes that fueled hatred in those targeted, and provided ongoing profits for military contractors, which benefited from war’s perpetuation (Press, “Wounds”).

In traditional warfare, soldiers are on the ground, fighting someone who could fight back. A soldier’s own life is at risk. However with a drone program, the risk is only in one direction. Lawrence Wilkerson, a retired Army colonel, shared his concern that this kind of remote warfare takes away a certain ethic. He stated, “‘if you give the warrior, on one side or the other, complete immunity, and let him go on killing, he’s a murderer. Because you’re

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killing people not only that you’re not necessarily sure are trying to kill you—you’re killing them with absolute impunity’” (Press, “Wounds”).

Sharing Their Story to Heal

One soldier shared how he enlisted after growing up in a violent home and wanted to defend the defenseless. He was an intelligence operative and during a mission in Iraq, he saw gunfire from a house and he ordered a missile. After the smoke cleared, he could not see a clear target, only the 19 dead bodies of men, women, and children. He shared this story while in tears at a VA chapel in Philadelphia, where others have come to share their story. After the veterans gave their testimonials, there was a circle formed around them to share a message of reconciliation. The psychologist and minister who facilitate these meetings share how important it is for there to be audience participation. They shared that “moral injury is as much about society’s avoidance and denial as it is about the ethical burdens that veterans bear” (Press, “Wounds”).

Response to Combat

Research shows that one of the ways combat veterans with PTSD struggle when they come back to civilian life is the perception of neutral situations as an actual threat. When startled or during a flashback, they may enter immediately into combat mode, which could result in a violent response. When these criminal cases are brought to court it is vital to determine if the person was capable of knowing, in that moment of violent action, that what they were doing was wrong and whether they were incapable of conforming their behavior (Jamshid Marvasti and Fatima Syed, “PTSD and the Justice System,” American Journal of Forensic Psychology, 36[3], 2018).

While some veterans may act out, others may struggle with suicidal thoughts. This violence and self-destructive behavior has been linked to PTSD. Research has shown that trauma survivors may repeat the trauma they experienced in order to establish ego mastery. A victim of PTSD may repeat the trauma on themselves or others, which may result in becoming desensitized and help them become a master over the trauma they themselves experienced. A victim to victimizer process may occur as the victim may identify with the aggressor (victimizer) in order to feel strong. It is a way to change from feeling powerless to powerful. This is similar to a child who fears monsters, becoming a monster himself during play with his siblings, in order to overcome this fear.

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Someone who has suffered through an atrocity and trauma may face several possible outcomes. These could be to gradually integrate the trauma and lead a healthy life; to stay identified as a victim; to become an offender themselves by identifying with their aggressor; and to become part victim and part offender.

Drugs and Alcohol Consumption

Combat veterans have been exposed to life or death situations and the threat of annihilation is the ultimate trauma. Armies have used drugs to calm the warrior and alleviate symptoms of PTSD. For example, in the Vietnam War soldiers at night, when on duty, might take amphetamine to stay awake, and be hypervigilant and hyper alert. In the morning, they would use alcohol to counteract the stimulation effects of the medication in order to sleep. It was documented that the Nazis gave their forces an amphetamine drug called Pervitin. In recent years, U.S. pilots were given amphetamines to help complete their bombing missions. This information only came to light when it was revealed by one of the pilots’ lawyers after he mistakenly bombed Canadian soldiers in Afghanistan. During the trial, his lawyer blamed the amphetamine drug for causing the fatal mistake (Josh White, “Air Force Pilot Who Bombed Canadians Is Fined $5,672,” Washington Post, July 7, 2004).

Sleep problems are one of the most painful side effects of trauma, and can cause cognitive functioning problems. A military psychiatrist told me that as he walked along the front line of combat in Iraq and Afghanistan, he was giving out medication for insomnia/nightmares “as if it was M&M’s for kids.”

Psychotherapy Focusing On: Self-Forgiveness, Guilt, and Self-Blame

Is there any effective special therapy for moral injury? Unfortunately, there is no scientifically confirmed treatment for moral injury. To the best of our knowledge, there is no medication or virtual exposure treatment that can repair moral or ethical damage to the psyche of the warrior. However, there are clinicians who focus on self-forgiveness and try to decrease self-blame and feelings of shame and guilt. Clinicians working with veterans’ war trauma may benefit from the following recommendations. Guilty feelings are a normal reaction in human beings. Clinicians can use these guilty feelings as an engine for amendments/compensation and self-forgiveness, rather than attempting to eradicate it.

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When clinicians are working with self-blame, they can help veterans understand that accountability and culpability should be distributed. Blame may be divided among the Commander in Chief, Congress, and their immediate superior who directed combat actions. Some veterans may feel betrayed by their commanders. This should be acknowledged and, if justified, may be dealt with through actions. Actions could include disclosure through writing to journals, social news media, and government officials. In psychotherapy, venting to one’s therapist can provide relief. The issue of killing the enemies and/or civilians should be discussed in treatment. Some veterans may hide their dark feelings and the therapist can softly explore their guilt around their actions in combat. This must be done from a space of nonjudgement. Although religion may be an important subject for some people in therapy, it is not helpful to tell the veteran, “It was God’s wish that you survived the enemy fire.” This could give the impression to the veteran that their co-fighter died because of God’s wish.

Therapists may explain the difference between guilt and shame. Feeling guilt is a normal human reaction and only a psychopath would not experience guilt. Veterans may have made mistakes in combat, and they may feel shame or guilt around this. Therapists can explain that coming from a place of guilt would be, “I am a good person, but I made a mistake.” However, a shame perspective would be, “I am the mistake.”

At times, “self-blame” should not be pathologized, as alternatives to self-blame may be powerlessness and helplessness. A person may feel that tragic events happen and that he/she has no control over it, which creates the image of a scary world. Many veterans may experience “survivor guilt,” when their comrade dies but they survive. This type of guilt should not be pathologized. One can explain in therapy that “bullets do not discriminate.” Someone with survivor guilt can utilize this guilt as an engine to help the family of the lost comrade or become an activist in peace organizations. Although veterans volunteered to join the military, they should be reminded that they did not create the war. Additionally, while in combat they were “ordered” not “invited” to shoot (Jamshid Marvasti and Anton Power, “Veteran Suicide, War Trauma and Moral Injury,” American Journal of Forensic Psychology, 34[3], 2016).

Conclusion

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As General Sherman declared, “War is hell.” We believe our veterans go through hell and may return back with injured souls and bodies. Our servicemen/women face grave physical and emotional risks while patrolling war zones, carrying 120 pounds on their backs in 130 degree temperatures in the Middle East conflicts. I believe the label of “battered soldier syndrome” is appropriate for those involved in combat: a place where civilian casualties and the death of comrades are occurring in front of their eyes. Additionally, moral injury and PTSD can still happen to drone operators while they are fighting the war from their offices.

Although the proverb states, “there are no atheists in foxholes,” there are those who survive the battleground that have lost their faith, and wonder where God was when they were exposed to the massacres and atrocities of war (Jamshid Marvasti, War Trauma in Veterans and Their Families, 2012, 299-300).

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