The warrior and moral injury

By Lt. Col. Douglas A. Pryer

Best Defense guest columnist

In May, after delivering a paper on moral injury to a break-out group at the Army Command and General Staff College’s annual ethics symposium, I asked for questions. The audience of about 40 junior field grade officers, nearly all of whom were combat veterans, and a few academics just sat there, stunned. Not knowing what to expect, I stepped out from behind the podium: "I know not everything I said is uncontroversial. What are your questions?"

My re-prompting broke the silence. The feedback was overwhelmingly positive. Several majors later approached me and thanked me, saying things along the lines of "you said what needed to be said." Whether the paper deserved such praise is questionable. There’s no question, though, that the subject struck a chord.

The current issue of ARMY magazine includes an abridgment of this much longer paper called "Moral Injury: What Leaders Don’t Mention When They Talk of War."

Here are the salient points:

-Defined as "perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations," moral injury is the proverbial "800 pound gorilla" that most active-duty combat veterans know is in the room but military culture won’t allow us to talk about.

-Moral injury is as real as PTSD. Ancient and modern literature and numerous mental health studies overwhelmingly support the existence of both. In 2012, Shira Maguen and Brett Litz, two of today’s leading researchers on moral injury, published an excellent summary of moral injury research titled "Moral Injury in Veterans of War." My long monograph samples more evidence

-Some warriors are afflicted with PTSD. Some with moral injury. Some suffer both. But the Hollywood stereotype of the troubled combat veteran is wrong: most veterans suffer from neither. The two conditions share some symptoms; other symptoms are unique to each. Self-handicapping behaviors (such as alcoholism, spousal abuse, and attempted suicide) are far more closely associated with moral injury than PTSD.

-The symptoms associated with moral injury are typically more resistant to treatment, more enduring, and more harmful to individuals, institutions, and society than those associated with PTSD.

-Moral injury isn’t a good fit for the Diagnostic and Statistical Manual of Mental Disorders (DSM). It doesn’t lend itself well to symptoms-based diagnoses. Although there are symptoms unique to moral injury; what makes moral injury "moral injury" is the source of the injury, not its symptoms. There’s no drug, surgery, or other physical remedy that helps treat the condition. Moreover, some psychologists believe that "moral injury" may sometimes be at the root of other diagnoses, such as Major Depressive Disorder and Dissociative Disorder. More research is needed to understand just how and where moral injury fits into the DSM (if it fits into the DSM at all).

-My own experiences align with what moral injury researchers report. I’ve had a few experiences that meet the criteria for sources of PTSD, but what bothers me most about these experiences is their moral context. Furthermore, thanks to this context, my most troubling experiences don’t even meet the criteria for PTSD.

-Although far from being the only factor, moral injury has almost certainly played a role in the rapid rise of military suicides since 2003. Surveys of Marines and soldiers indicate that many may feel morally conflicted concerning certain experiences downrange. Even a cursory review of current literature (Jonathan Shay’s Achilles in Vietnam and Odysseus in America, Joshua Phillips’ None of Us Were Like This Before, Nancy Sherman’s The Untold War, Edward Tick’s War and the Soul, David Finkel’s Thank You for Your Service, Tony Lagouranis’ Fear Up Harsh, Tyler Boudreau’s Unpacking Inferno, etc.) supports a link between suicidal ideation and strong feelings of guilt and/or shame.

-Moral injury is a significant soldier readiness issue. Nonetheless, our military is not systematically or comprehensively collecting the data that would confirm or deny the link between moral injury and self-handicapping behaviors. Senior leaders often know, for example, that a suicide victim drank too much alcohol. They don’t know, however, what may have driven this victim to drink. Until we understand deeper causes, we will not meaningfully reduce or prevent such negative outcomes from psychological injury as suicide.

-One effect of the rise of remote-controlled warfare will be that moral injury will assume an increased share of war’s psychological injuries. Remote-control warriors do not suffer life-threatening duress in combat, and they don’t vicariously experience extreme stress via the experiences of individuals they know and love (such as their witnessing a fellow platoon member being shot and killed). This means they’re immune from most forms of PTSD, as this condition is currently defined. They’re also immune from Traumatic Brain Injury (unless they spill their coffee and slip on it). They’re not immune, however, from moral injury. The potential for moral injury in combat veterans will only grow as sensors on "drones" and other remote-controlled machines improve. Soon, there will be little subjective difference between a WWI infantryman bayoneting an enemy soldier and what a drone pilot/sensor operator experiences when they kill someone.

-Cultivating resilient warriors is important. More important is enabling service members to perform only those actions in combat they can long live with.

-Not all moral injury is preventable, but, in general, it’s more preventable than PTSD or TBI. In the orders they give and the actions they permit, leaders — not mental health professionals — play the crucial role in reducing this form of psychological injury. 

-Today, moral opinion often coheres quickly and across huge demographics. Thus, while perceptions of justice (Thucydides’s "honor") have always mattered in human conflict, they matter more in the "information age" than they ever have. These perceptions help determine the psychological aftermath of war as well as inspire and maintain the will to fight that ultimately "wins" wars. Many members of our national security community — focused on technological silver bullets, short-lived tactical outcomes, and zero-sum calculations (body counts) of what constitutes the "defeat" of a given enemy — fail to even consider this reality, let alone adequately account for it in the actions they order, permit, recommend, and/or perform on today’s battlefields.

Lieutenant Colonel Douglas A. Pryer is an active-duty counterintelligence officer who has deployed to Kosovo, Afghanistan, and Iraq. He has published one book and numerous essays on the human domain of war. The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. government.