In 2009, suicides in the active duty military surpassed the general population rate for the first time. A Pentagon study published in August 2013 claimed the rates were not affected by combat, but their study was of active duty and recently retired military. Veteran Affairs clinicians tell a different story for veterans.
Veteran suicide rates are alarmingly high. At twenty-two a day, they are three times the civilian rate, and combat takes a disproportionate toll. Those who have killed have a two to three times higher rate of suicide than other veterans, even when other factors, such as PTSD, mental illness, or drug and alcohol abuse, are factored out. Also noteworthy is this detail: the average age of veteran suicides is around 55 whereas it is 43 for civilians.
Why this age difference? In late 2009, a group of VA clinicians suggested that a major factor in veteran suicides was moral injury. Moral injury occurs when a war combatant violates deeply held moral beliefs and can no longer make sense out of the world. Vietnam veteran and philosopher Camillo "Mac" Bica describes it as the destruction of moral identity. Retired VA psychiatrist Jonathan Shay in Achilles in Vietnam explains it as the unmaking of character. It happens in many ways: killing; failing to stop an atrocity or committing one; having to follow an order or fight a war one thinks is wrong; failing to save a friend's life; or treating human remains disrespectfully.
Moral injury is a response of personal agency and is different from PTSD, which is an involuntary victim reaction to terror under life-threatening conditions that affects the limbic brain system. Harvard psychiatrist Judith Herman notes in Trauma and Recovery that once severe symptoms of PTSD calm down, moral questions emerge.
Shay insists that moral injury is not a clinical condition that can be treated with individual counseling. It is a responsibility of our whole society, especially of communities where veterans live and work. Yet, as many veterans attest, their struggle to come home after war is aggravated by civilians because we are largely clueless about what is truly required to bring people all the way home.
The long legacy of war -- the struggle revealed in veteran suicides, homelessness, divorce, poverty, incarceration, and unemployment -- accumulates as a weight that takes a toll over time. And even those who have not deployed to a war zone, for example, pilots during the cold war trained to drop nuclear warheads or today's drone operators, report symptoms of moral injury. Even chaplains and other caregivers can experience secondary reactions of both PTSD and moral injury -- in early August, I spent four days with a hundred military and VA chaplains, some of whom had deployed multiple times, and they helped me understand these reactions more clearly.
The Soul Repair Center was founded to train civilians in supporting veteran recovery from moral injury and to conduct research on the most effective means for recovery. Here are things we have learned:
1.Acceptance: The person who left for war will never be the same. Veterans may be unwilling to share their experiences for a variety of reasons such as feelings of deep shame or fear of traumatizing others. War's profound losses, grief, anger, and dislocation devastate anyone with a capacity for empathy and a moral conscience.
2.Deep Listening: Veterans need to tell stories in order to process their moral struggles, and they need trusted friends and a community that can listen to the many times stories need to be told. This kind of listening is not common in our polarized society. It is a deep listening, from the heart. It requires us to be vulnerable, emotionally honest, and open and to receive another's inner struggle without judgment and without thinking of a response or our own opinion.
3.Non-Judgmental Moral Authority: Profound moral ambiguities and questions are impossible to process alone. People who understand moral anguish, questions about evil, and the difficulty of forgiveness are crucial. Pat moral answers, cheap forgiveness, arguments about politics, and religious platitudes or formulas offer little to someone experiencing moral injury.
4.Processing Grief and Lamentation: War denies the fullness of grief. Sorrow makes one vulnerable, so it may erupt as anger or a rage for vengeance. Such chaotic, powerful feelings need a group process that offers compassion, wisdom, and care over a long time. Without means to protest and grieve their losses, to acknowledge guilt or shame, and to express anger and outrage, veterans will lack what is needed to reach acceptance and resolution. Painful memories resurface because of anniversary dates or unexpected reminders, so these processes are cycles, not destinations.
5.Patience and Persistence: No one forgets what happened in war, but over time, as the stories of moral injury are processed, they can be put in perspective and not remain the only thing that defines a life. A civilian community offers perspectives for looking forward and building a life out of war's ashes.
6.Service Opportunities: Veterans have committed part of their lives to serve a cause larger than themselves, and they often seek ways to be of service to others. They seek to repair the world after they have seen death and destruction, and it can be a powerful way to make amends and reclaim a moral self.
7.Friendship: The intense urgencies of war are hard to turn off, especially the intense bonds of camaraderie in battle. Veterans need close and trusted friends who can join them to decompress, to relax, to be in soothing, beautiful places, and to learn to enjoy simple things again.
Without understanding how war changes people for the rest of their lives, we will continue to consign many veterans to civilian hell and to a self-inflicted end to such suffering. While we cannot forgive veterans for harm done to others, we can accompany their recovery toward self-forgiveness.
Whatever we think of war, we have this responsibility.
This post is part of a special Huffington Post series, "Invisible Casualties," in which we shine a spotlight on suicide-prevention efforts within the military. Every weekday in September, we'll feature a different blog post by someone who is either an expert in the field, who has been affected by a suicide, or who has contemplated suicide. To see all the posts in the series, as well as original reporting, audio and video, click here.
If you or someone you know would like to contribute to our series, send an email toimpactblogs@huffingtonpost.com.
And please, if you or someone you know needs help, call the national crisis line for the military and veterans, 1-800-273-8255, or send a text to 838255.