I just got back from the 23rd and final NICABM conference in Hilton Head – a terrific close to an incredible string of first-rate, cutting edge conferences, featuring the very newest ideas and practices for clinicians – just a stellar group of speakers and participants.  

One of the ideas that I introduced during my pre-con and again in a plenary talk was that of “Moral Injury”, and how our returning Service Members suffer from this in profound ways.  Although I was mentioning it as a sidebar, people kept coming back to the term, asking about it, pondering it in other contexts.  It really grabbed them.  It clearly was something the providers and clinicians at the conference really wanted to wrestle with, chew over, and apply to the people they served, not to mention their own struggles.

I first heard the term from Charles Hoge MD, a leading researcher on the impacts of the wars in Iraq and Afghanistan on returning soldiers.  He’s surveyed thousands of military personnel.

Another researcher, Boston University’s Brett Litz PhD, defines a moral injury experience as "perpetrating, failing to prevent, bearing witness to or learning about acts that transgress deeply held moral beliefs and expectations."

As reported by Mark Walker in the North County Times last year, Litz feels that service members who don't talk to loved ones, clergy or some other confidant will become entrenched in the idea that they did is unforgivable. This can lead to profound withdrawal, self-condemnation, avoidance and of course suicide.  And there’s a lot of suicide going on – not just with returning warriors but their spouses, partners and kids.

Treating troops with moral injury, they say, requires a deeply caring and respectful therapeutic relationship, and a dialogue with a "benevolent moral authority", like a pastor. They also say that a protocol of doing good deeds as a way of making amends can be an important addition to the life of someone who has experienced this unique form of heartache.

Just being witness to the age-old carnage of war is enough to create moral injury.  But, as most of us have come to learn, the nature of insurgent wars, where the enemy blends in with the population, increases moral ambiguity and creates an anguish of the first order, because innocent civilians get killed. Troops are called upon to kick down doors and destroy whole families.
Providers and therapists have to be acutely aware of this particular form of pain that infuses the return home of countless warriors, when they have the time and space to look back at their experiences in the context of “normal” civilian life (whatever that is).

Couple this with the fact that when those brave enough to finally seek help meet up with a counselor or therapist, they can be sitting across from someone who averts eye contact.  Yep, that’s a frequent complaint, people.  Their counselors can’t look them in the eye.  What does that say to someone who’s already feeling sullied, deeply ashamed, beyond the pale, unfit for normal social interaction?

I’m sure these therapists aren’t aware that they’re doing this, and haven’t a clue what they’re signaling.  I mean, this is rule #1 of any idiot’s guide to doing therapy, so I’m certain this is unconscious behavior on the clinician’s part.  But it’s got to stop.  We must bring our colleagues (and ourselves) up to speed on the moral wounds of war and how to remediate the profound suffering they produce.  It doesn’t matter what our political position is about these wars.  When it comes to alleviating the suffering of our soldiers, we need to understand that our politics are irrelevant.  We attend to the suffering at hand.  

And, make no mistake about it, we’ll hear about things - impossible and grotesque choices - that can create moral injury for us.  That comes with the territory of good listening.

Take care, be well.