John Fisher got his soul back when he visited a cemetery in Greece.
Shelley Corteville felt "rocketed" into healing when she told her story at a veterans' retreat after 28 years of silence.
Bob Cagle lost his decades-long urge to commit suicide after an encounter at a Buddhist temple.
These veterans and thousands like them grapple with what some call "the war after the war" — the psychological scars of conflict. Working with the U.S. Department of Veterans Affairs and private organizations, these men and women are employing treatments both radically new and centuries old. At the center of their journey is a new way of thinking that redefines some traumas as moral injuries.
The psychological toll taken by war is obvious. For the second year in a row, more active-duty troops committed suicide in 2010 (468) than were killed in combat in Iraq and Afghanistan (462). A 2008 RAND Corporation study reported that nearly 1 in 5 troops who had returned from Iraq and Afghanistan reported symptoms of post-traumatic stress or major depression.
Since the American Psychiatric Association added post-traumatic stress disorder, or PTSD, to its diagnostic manual in 1980, the diagnosis has most often focused on trauma associated with threats to a soldier's life. Today, however, therapists such as Jonathan Shay, a retired VA psychiatrist and recipient of a MacArthur Foundation "genius" grant; Edward Tick, director of the private group Soldier's Heart; and Brett Litz, a VA psychologist, argue that this concept is too limited. What sometimes happens in war may more accurately be called a moral injury — a deep soul wound that pierces a person's identity, sense of morality and relationship to society. In short, a threat in a solder's life.
"My colleagues and I suspect that the greatest lasting harm is from moral injury," says Litz, director of the Mental Health Core of the Massachusetts Veterans Epidemiological Research and Information Center. He and six colleagues published an article on the topic in the December 2009 Clinical Psychological Review, in which they define moral injury as a wound that can occur when troops participate in, witness or fall victim to actions that transgress their most deeply held moral beliefs.
While the severity of this kind of wound differs from person to person, moral injury can lead to deep despair.
"They have lost their sense that virtue is even possible," Shay says. "It corrodes the soul."
The Sept-Oct 2011
This article appears in our Sept-Oct 2011 issue under the title "Moral Injury." To see more articles from this issue, go to the Sept-Oct 2011 magazine page on Miller-McCune.com.
Litz acknowledges that the idea of moral injury is "controversial and provocative." Neither the military, VA nor the American Psychiatric Association have sanctioned this as a diagnosis, but the concept is gaining traction. In April, psychologists, officers and chaplains led a plenary session on the topic at the Navy and Marine Corps Combat and Operational Stress Control Conference in San Diego.
In Europe, post-traumatic stress disorder researcher Ulrike Schmidt even seeks evidence of the moral injury in brain tissue itself. As she told Miller-McCune.com recently, "They need to know that it's a recognized disorder. They are not weak, they're sick, they have a spiritual wound. ... And it's important that they aren't treated like outsiders, which is how many soldiers were treated in Europe in the '40s and '50s."
Georgetown University ethics professor Nancy Sherman heard stories of moral trauma when she interviewed veterans of Iraq, Afghanistan, Vietnam and World War II for her 2010 book, The Untold War. "It might be where you felt you should have been able to do more for your buddies, but you couldn't, or because you simply survived," she says.
"Regret," she writes, "doesn't begin to capture what the soldiers I talked with feel. It doesn't capture the despair or depth of the feeling — the awful weight of self-indictment and the need to make moral repair in order to be allowed back into the community in which he feels he has somehow jeopardized his standing."
Vietnam veterans John Fisher and Bob Cagle know that weight. Fisher served as a forward artillery observer and assistant gunner in 1968 and 1969. He vividly remembers the first time he shot an enemy soldier.
"I realized that I had taken his soul away from him," Fisher says. "In the process, my soul was gone."
Cagle served as an infantryman from 1965 to 1966. When he first killed a soldier in combat, he immediately thought of the commandment: "Thou shalt not kill."
"Well, I guess I screwed that up," Cagle told himself at the time. "God will never forgive me."
When Cagle saw the body and realized that his enemy looked no older than 14, his guilt deepened. "He would have shot me in a heartbeat, I had no doubt, but I just couldn't get over that."
Fisher and Cagle came home to thoughts of suicide. "I literally couldn't condone any of the things I had to participate in to save my own life," Fisher says.
Although both eventually found successful careers (Fisher as a chiropractor and Cagle as a respiratory therapist), they struggled, enduring failed marriages, flashbacks and fits of anger and anxiety.
Moral injury does not always occur on a battlefield. In more than 20 years of treating veterans, MacArthur Fellow Shay concluded that these wounds most often occur when leaders betray soldiers in high-stakes situations, whether or not that occurs in combat.
Shelley Corteville, for example, was an Army air traffic controller from 1978 to 1980 in South Korea, where she was raped five times by a fellow soldier. The fault, she thought, was her own. After all, other soldiers and officers constantly referred to women as "whores or tramps" who were always "asking for it." She did not believe these same officers would punish a rapist, so she kept silent, working side-by-side with the man every day.
After leaving the Army, Corteville drank heavily, married and divorced repeatedly. She moved 58 times and worked at 29 different jobs.
Therapists have devised a variety of treatments. Litz and his colleagues represent a traditional approach, using a modified talk therapy where a patient interacts with a therapist in an office. Their approach includes creating a bond between the patient and a therapist who can accept unconditionally and listen "without revulsion." Therapists also guide patients through an imaginary dialogue with a "benevolent moral authority" and help them plan practical tasks to make amends.
Litz and his colleagues tested their therapeutic strategy on 25 active-duty Marines in a pilot project. This summer, they launched a four-year study with 300 Marines struggling with moral injury and other psychological problems.
Tick represents a different approach. He sees talk therapy as a dead end. "We can only do so much review and expression and catharsis and processing," he says. "That's all wonderful and necessary, but combat veterans who have participated in destroying the world can be stuck in their grief and in their identity of being a destroyer."
He uses groups where veterans share experiences, but he also turns to ritual, charity work, visits to former battlefields and even a redefinition of what it means to be a soldier.
Tick, his wife and co-director, Kate Dahlstedt, and a tiny staff at the nonprofit Soldier's Heart in Troy, N.Y., have worked with several hundred people, including active-duty service members and veterans of Iraq and Afghanistan. At the core of their approach is a redefinition of soldiering based on Tick's research into warrior traditions as discussed in his 2005 book War and the Soul.
"In traditional cultures, warriors always came back to tell their stories, to give witness and to do healing ceremonies in front of the entire community," Tick says. "The community witnessed the stories, felt the emotions, carried the burdens with their warriors and transferred responsibility for actions from the warriors to the community."
Today, Tick, and veterans and civilians inspired by his book, are attempting to re-create some of those experiences from the past. Volunteer groups in 18 U.S. cities, Canada and Vietnam hold listening circles, where veterans share stories with each other and civilians, and veterans mentor each other. Tick also leads trips to ancient and modern battlefields.
No in-depth data yet exists on the effectiveness of any form of treatment for moral injury. Litz's study is the first large-scale effort to do that; he says some of Tick's methods "make sense conceptually," but he will not comment further without seeing data. So far, most of the evaluation of Tick's results has been anecdotal.
Fisher, Cagle and Corteville have all worked with Soldier's Heart.
Corteville, 51, of Springfield, Ore., went to her first retreat in 2009. She had already been through five years of counseling with the VA and been sober for 17 years. "In all that time, I still hadn't dealt with my PTSD," she says.
At the retreat, Corteville finally talked about being raped. "That very first retreat is what rocketed me into healing." As a result, she left a failing marriage and is working on a degree in sociology.
Fisher, 63, of Murrells Inlet, S.C., contacted Tick after reading his book. Despite years of therapy, Fisher was still "waking up in the middle of the night screaming." Fisher's breakthrough came when he accompanied Tick to Greece, and they visited the Kerameikos cemetery.
Fisher sat on a knoll and listened as Tick read an oration for the war dead that had been delivered on the same spot 2,500 years before. Fisher says he felt like he was floating, and he realized that his soul, his sense of self, had fled his body while he was in Vietnam. "My heart felt like it was dark inside before. Now it felt like someone had turned on the light."
Fisher returned home and ended a bad marriage. Today, he leads Soldier's Heart trips to Vietnam, where veterans meet former foes and conduct charity projects.
Cagle, 65, of Atlanta, views healing as a process. For him, the most useful activity has been writing about his experiences. But the turning point came when he returned to Vietnam with Tick. At first, the trip was a nightmare, as Cagle suffered constant flashbacks and saw visions of the young soldier he had killed. Eventually, the group climbed to a Buddhist temple on a mountain. While the others took off their shoes, Cagle looked up and saw the boy.
"I don't even know how to describe it." Cagle struggles to speak as he retells the story. "I'm trying to get my voice back." He pauses. "Ed [Tick] came over and said, 'Let's go on in.'
"I said, 'You don't see him, do you?'
"Ed said, 'Who?'
"I said, 'That's the boy I shot.'
"Ed said, 'What's going on?'
"I said, 'I think we're talking to one another on some level I don't get.'"
Cagle says he felt a crushing weight slip off his shoulders. "From then on, my whole everything lightened. I felt relieved. I felt like this kid could finally go wherever he was supposed to go. That's when I really started healing."
Today, Cagle helps run Veterans Heart Georgia. Healing takes time, but it is possible, he says. "It's not a group of 500 people getting together and having some great epiphany. It's a one-on-one process. It's people who care about one another, who are trying to heal themselves and others."