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How Do We Repair the Souls of Those Returning from Iraq?

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[Rev. Dr. Gabriella Lettini co-authored this piece. We led the team that organized the Truth Commission on Conscience in War and are members of the leadership team for "The Soul Repair Project."]

By year's end, 40,000 U.S. troops will return from Iraq and, according to President Obama, "America's war in Iraq will be over." But the long nightmare of the Iraq War will not be over for either side of the conflict. The U. S. will see a new surge of suffering, and it will not be over for generations.

The fatalities will not end when the troops come home. Though veterans are only 7% of the population, they are 20% of all U.S. suicides, 6000 a year, an average of 18 a day. Veterans under 30 have record-breaking suicide rates, despite mental health screenings for returning troops, better research on and treatment of PTSD, and increased VA suicide prevention programs. Between 2005 and 2007, the rate among veterans under age 30 rose 26%; in Texas, rates rose 40% between 2006 and 2009.

Recently, VA clinicians proposed another cause for suicide, a wound they call "moral injury," which may aggravate or precipitate PTSD. As Harvard psychiatrist Judith Herman notes in Trauma and Recovery, once someone begins to recover enough from PTSD to construct a coherent memory of their trauma, they can reflect on their experience. Then, the moral and religious questions emerge.

Moral injury is a wound in the soul, an inner conflict based on a moral evaluation of having inflicted or witnessed harm. It results from a capacity for both empathy and self-reflection on moral values, which means it happens to healthy human beings. The current wars are especially morally compromising because the lines between innocent civilians and combatants are so blurred. Even women, children, and pets can be dangerous or be used as shields.

Though an action in war may have saved someone's life or felt right at the time, a veteran may come to feel remorse, shame, or guilt for having had to inflict harm that violates his or her core values. Moral injury can result not only from active behavior, such as torturing or killing, but also from passive behavior, such as failing to prevent harm or witnessing a close friend be slain. And it can involve feeling betrayed by persons in authority. Just having to view and handle human remains can sometimes cause it.

In betraying their most deeply held moral beliefs, veterans often cannot forgive themselves and can no longer make sense of the world. They often abandon their faith. Such moral anguish is not PTSD, not a temporary medical or psychiatric disorder to be "treated," but a lifelong spiritual and moral struggle to live honestly, courageously, and compassionately with memories of war. It can take a long time to reconstruct a world of meaning in which it is possible to see how one's life matters to others.

The term moral injury names a deep and old dilemma of war. It may be a new clinical concept, but the moral anguish of warriors defines much literature about war from ancient times, such as the Greek Iliad, Indian Bhagavad-Gita, and the Hebrew prophets in the Bible, to the present, in memoirs of the wars in Afghanistan and Iraq. However, secular clinical approaches to such feelings usually treat them as neuroses that inhibit individual self-actualization and interfere with authentic urges and feelings. Veterans are, therefore, often misunderstood and struggle with moral conscience, loss of meaning, and spiritual despair in isolation.

In Packing Inferno: the Unmaking of a Marine, Tyler E. Boudreau, a former Marine Captain and veteran of Iraq, reflects on the apparent inability of societies to learn about the torture war inflicts on the souls of veterans, despite the many witnesses in works of art and history. He concludes that societies have understood it only as much as they really wanted to learn about it and its deeper meaning. For instance, after World War I, the prescribed process of reintegration silenced and pathologized the moral suffering of veterans, treating "shell shock" as an individual inability to put war behind.

Not everyone was so unable or unwilling to understand, Tyler observes. In Mrs. Dalloway, Virginia Woolf portrayed the suicidal anguish of Septimus Smith as if she were a veteran herself. Tyler notes:

She was just a writer. That tells me, if nothing else, that the information was there. The capacity to know existed. It wasn't beyond human understanding. They weren't too primitive. If Virginia Woolf knew about combat stress, everybody else could have known, too. They did not know because they didn't want to know.

Still, not even Tyler could face telling the truth about war. After he left the Corps, he worked as a Casualty Assistance Calls Officer (CACO), which required him to call the parents of wounded Marines. He could not bring himself to call soldiers' families and report honestly that, among the wounds they suffered, "Your boy is coming home with a broken heart." Never once was he able to say it, and he regrets it still that he did not.

We have to support veterans in telling the truths of war. Though the term moral injury is new among VA clinicians, the concepts underlying it ring true to many spiritual and religious people. We know that the loss of faith and meaning, the sense of isolation, and the self-condemnation characteristic of moral injury cannot be repaired by short-term therapies. While around 90% of the public claim a spiritual affiliation, only around 40% of clinicians claim one. VA psychiatrist Jonathan Shay, who received a MacArthur "genius" award for his work on PTSD, noted in 2002,

Medical-psychological therapies...are not, and should not be, the only therapies available for moral pain. Religious and cultural therapies are not only possible, but may well be superior to what mental health professionals conventionally offer.

Rev. Dr. Kent Drescher, who works with veterans, notes that the more judgmental and punitive a veteran's idea of God and religious authority, the more difficult is the recovery from moral injury. Veterans who grieve the losses of war and seek ways to make amends for the harm they have done need trusted places to have conversations about meaning and ethics with others who understand such issues. They need the company of others who understand the lifelong struggle to be their best selves after they have violated their deepest moral values. Recovery includes the restoration of trust in a power strong enough to carry the weight of all inner anguish and honest prayers, and, for many, it comes through trusting in a benevolent spiritual power who is deeply moved by injustice, violence, and human suffering.

Religious professionals are familiar with the personal transformations that occur in worship and community practices when they are repeated over time. Such activities embed the moral values of the community in the whole person and support their being lived out. More veterans seek counsel from clergy than from clinicians, and the clergy they need are those willing to offer a benevolent and caring presence. In addition to veterans who seek out clergy themselves, those in clinical treatment who ask moral questions and express grief, contrition, and shame are usually referred to chaplains because the formal training of mental health professionals does not include theology, discussions of faith, or philosophical questions about evil.

Veterans who do not identify as either spiritual or religious also need communities where they can explore their moral struggles and address their moral injury. More such spaces need to be created, and more civilians need to be trained in understanding the moral injury of war. Whether support for moral injury in veterans occurs in religious or secular spaces, we civilians must understand that we are not only to serve as witnesses of veterans' struggles, but we must also engage in our own ethical questioning in relation to war.

Moral injury is not only about "them;" it is also about "us." In his powerful testimony at the Truth Commission on Conscience in War, Tyler Boudreau challenged the members of the audience to remember that they will never be able to speak the truth about war until they can speak the truth about themselves. Moral injury is an issue for civilians, not just veterans. Regardless of our personal positions on a war, a society that engaged in warfare must come to terms with its responsibilities for its effects and with its own moral injury.

The hidden wounds of war do not heal when left unattended; instead, they may fester for years in depression, homelessness, addiction, and a half-lived existence finished by suicide, which doesn't end the suffering for those who knew and loved the one who died. Unattended, moral injury will linger for generations. Understanding moral injury is a necessary first step in a much longer societal healing process. We should begin that process today.

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