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Moral Injury: The Crucial Missing Piece in Understanding Soldier Suicides

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This piece was co-authored by Col. Herman Keizer, Jr. (ret.), Co-Director of the Soul Repair Center, who served for 34 years as a military chaplain, and Dr. Gabriella Lettini, co-author of 'Soul Repair: Recovering from Moral Injury After War,' Beacon, forthcoming November 2012.

The crisis of military suicides, averaging one a day, has captured national attention. The July 23 cover story in Time magazine summarizes much of this coverage. Unfortunately, it is misleading.

The article presents the suicides of two officers -- a helicopter pilot who served in Iraq and a medical doctor who did not serve in Iraq or Afghanistan. This example skews the article in two ways. First, in focusing on officers, it selects a group that tends to see less direct combat than the enlisted men who both do more direct fighting and commit suicide at higher rates than officers. Second, in contrasting the two officers' deaths, it suggests that suicide rates are the same for those who serve and those who do not serve in combat. However, the medical doctor first was an enlisted soldier who worked on a bomb squad and served in Bosnia. He was also in Oklahoma City just after the federal building was attacked -- years before he decided to become a doctor. It's likely he saw war conditions during his earlier service. We need to remember that the U.S. has sent its forces into violent conflicts every year since World War II, except one, so Iraq and Afghanistan are not the only ways a soldier may have experienced combat.

The most serious blind spot in the reporting on military suicides is an absence of discussions about the moral impact of military training and its implementation in combat. Soldiers are trained to kill, which is regarded as criminal behavior in civilian life, and they are trained to be lethal without even thinking about it, a method of training called reflexive fire training.

We suggest that moral injury is likely one of the most important factors in military suicide rates.

Moral injury is not PTSD. The latter is a dysfunction of brain areas that suppress fear and integrate feeling with coherent memory; symptoms include flashbacks, nightmares, dissociative episodes and hyper-vigilance. PTSD is an immediate injury of trauma.

Moral injury has a slow burn quality that often takes time to sink in. To be morally injured requires a healthy brain that can experience empathy, create a coherent memory narrative, understand moral reasoning and evaluate behavior. Moral injury is a negative self-judgment based on having transgressed core moral beliefs and values or on feeling betrayed by authorities. It is reflected in the destruction of a moral identity and loss of meaning. Its symptoms include shame, survivor guilt, depression, despair, addiction, distrust, anger, a need to make amends and the loss of a desire to live.

While the Army has long provided protective training for soldiers sent to war, this is clearly now inadequate. Battles with insurgencies make violence against civilians commonplace and acceptable in ways that violate international standards for the conduct of war and the moral code of conduct for soldiers. For example, "Sniper Wonderland," a military drill chant says:

See the little girl with the puppy;
Lock and load a hollow pointed round...
Take the shot and maybe if you're lucky;
You'll watch their lifeless bodies hit the ground....

The most recent Army attempt to prepare troops for battle appears to have failed miserably. Its "Comprehensive Soldier Fitness" (CSF) program, begun in 2009 with a $125 million investment and lauded in a New York Times Magazine article in March 2012, has been widely criticized. It bypasses the difficult ethical questions that many healthy human beings ask about war, and its spiritual fitness component has no moral content. It suggests that a soldier's commitment to a higher purpose -- mission first -- makes for resiliency. But most people capable of such a commitment also have empathy for others and deep moral values.

The Army's "spiritual fitness" encourages soldiers to see events in a neutral light, rather than labeling them as good or bad, and to create a nightly list of positive things that happened that day. The lack of awareness is startling regarding what it might mean to ask someone to think of killing a child, losing a close friend or torturing detainees as neutral or positive.

Proving a direct cause-effect relationship between such training and suicides is difficult, of course. However, there are certain moral reactions to war and the experience of combat training that indicate a violation of moral conscience in war can have devastating inner consequences in soldiers. A larger proportion of soldiers and veterans who serve in combat seek the counseling help of a chaplain over the help of a clinician. This choice has two likely reasons. First, speaking to a chaplain does not create a negative psychological record in a military career. Second, psychological training does not require knowledge of theological issues, moral discussions of good and evil, or religious meaning. In fact, when soldiers raise moral questions about conscience in therapy, they are often referred to clergy.

The reporting on military and veteran suicides mostly fails to explore the role of moral injury. When a suicide occurs years after a soldier returns from war, combat experience is often disregarded as a primary cause of the suicide. Yet, as Karl Marlantes, a Vietnam veteran, reports in "What It Is Like to Go to War," he was fine for a decade, and then, he crashed. Often, such delays are used to deny VA services or are regarded as a family problem, rather than as a consequence of service in combat.

The alarming rates of reported suicides are squishy statistics and do not reflect the true numbers of soldiers who take their own lives. Many combat veterans tell stories of comrades who shot themselves, but who were reported as "non-combat" or "accidental" casualties. Soldiers who deliberately place themselves in harm's way in hopes of dying are reported as casualties, not suicides. Since many life-insurance policies will not pay benefits to families if suicide is the cause of death, the need to disguise suicide may mean some apparently accidental deaths were, in actuality, planned. We will never know the true suicide numbers, but we do know moral injury causes intense inner anguish.

Moral injury is not a clinical condition that can be medicated or cured by psychology. It requires the reconstruction of a moral identity and meaning system with the support of a caring, nonjudgmental community that can provide a way for veterans to learn to forgive themselves. But any community that wants to offer such support must have the moral courage to examine its own responsibility for war. With such a small percentage of Americans (1 percent) serving in the military, and the escalating unpopularity of the wars in Iraq and Afghanistan, too few people or communities remember the initial popularity of the wars or care about the cost to the men and women we send to fight on our behalf.

We care, and we believe our whole society bears responsibility for addressing moral injury. Whether or not we supported the wars, they do not end when soldiers come home. Instead, they continue in the souls of those who fought and in their families and communities when they return to civilian life. That is why we believe one right response of moral conscience to military and veteran suicides is to study and address moral injury as a hidden wound of war.