"Moral Injury" a Key Factor in Rising Suicide Rates Among U.S. Veterans

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Posted Feb. 6, 2013

Interview with Rita Nakashima Brock, founding co-director of the Soul Repair Center at Brite Divinity School, conducted by Scott Harris


There is a growing body of knowledge exploring the issue of "moral injury" among veterans returning from America's wars in Iraq and Afghanistan. The condition results from a conflict between an individual’s view of one's moral self and one's behavior in war. Moral injury can occur along with PTSD or post-traumatic stress disorder, but the two conditions have different origins.

In recent years, the nation has witnessed a steep rise in the number of military veterans committing suicide. Last year, more active-duty U.S. soldiers killed themselves than died in combat. In a recent report, the Department of Veterans Affairs found that the number of suicides among veterans reached 22 a day in 2010, the most recent year available. That was a 22 percent increase from 2007, when the daily number of veterans taking their own lives was 18. Rita Nakashima Brock, the founding co-director of the Soul Repair Center at Brite Divinity School in Fort Worth, Texas, and previous director of the Fellowship Program at the Radcliffe Institute for Advanced Study at Harvard University, maintains that moral injury is likely one of the most important factors in military suicide rates. She believes that society needs to examine the link between military suicides and the moral impact of military training and its implementation in combat where soldiers kill.

Between The Lines’ Melinda Tuhus spoke with Nakashima Brock, who from 2001-2002, was a fellow at the Harvard Divinity School Center for Values in Public Life. Here, she explains the difference between moral injury and PTSD, the ways in which therapists and clergy are working to help veterans deal with the condition, and the responsibility of society at large to support those returning soldiers suffering with this psychological injury.

RITA NAKASHIMA BROCK: Moral injury is the impact on a person's moral conscience and sense of being a moral self in relation to war service, and it can come from actually having done something that you might think is wrong, but it can also just come from doing your duty in war and then returning home and beginning to think about the moral implications of war service. It's been confused with PTSD because it can occur at the same time – they overlap – but PTSD is indication of damage to your limbic brain, your emotional-perceiving brain system that processes experience and calms down fear, and when that's injured, there's a clear symptom profile for PTSD because you're not able to calm down fear and that part of your brain isn't working very well. Moral injury is different. It's actually the healthy function of your thinking, executive brain, where you do moral reasoning, collect memories and think about them and reflect on them in moral terms. So a person who's a healthy moral person can experience some kind of extreme condition and begin to lose their bearings in terms of being able to figure out what's right and what's wrong. And they can't do that if their executive brain isn't functioning. I think moral injury is actually quite common in anyone who's served in war; I think we just haven't had a way to talk about it, but you see it in war literature; it's in parts of the Bible; it's in war poetry. It's that kind of anguish that you hear in the voices of people who've returned from war. The VA – the Veterans Affairs (sic) clinicians have actually suggested recently that it might be a greater factor in veterans' suicide rates than PTSD, and I think that's right. It's really a weird thing we do. We take normal people who've been taught that killing is a criminal activity and then train them, because it's important for them to learn how to kill. But there's also a moral code in the military. It's not like the training is wanton violence. There are rules of engagement; you're not supposed to kill civilians and things like that. But in the context of war, a lot of that stuff can go haywire in emergency situations. And in a counter-insurgency operation, you're shooting at civilians; there aren't any soldiers in uniforms, and so it can become very confusing and anguishing to even be in a war like that.

BETWEEN THE LINES: Rita Nakashima Brock, does the VA recognize moral injury as a specific diagnosis?

RITA NAKASHIMA BROCK: No, not that I know of. I know that they've been trying to figure out how to collect data to make it something they could treat. But I think, in fact, it's the kind of thing you don't get over. I think you learn how to cope with it and live with it, and rebuild a civilian identity, because it's like you're living in two moral universes – you're living in the civilian moral universe and then you're living under the military moral codes. Then you leave the military and come back into civilian life, and those are clashing codes; they don't align well. So you have to figure out how you're going to be a decent person in civilian society again. But the VA did actually publish an essay – a group of VA clinicians at the end of 2009, published I think the first sort of scholarly, clinical paper on moral injury, in which they suggested it was different from PTSD and that it was a factor in the difficulty veterans were having re-assimilating into civilian society, and they even suggested an eight-step protocol for clinicians to help veterans work through moral injury.

BETWEEN THE LINES: Can you summarize what those steps are?

RITA NAKASHIMA BROCK: They have to do with needing a community of support to help you recover, to give you a chance to talk about what happened without judging you, to talk about your moral questions, your faith questions, like if you don't believe in God anymore, what happened to you, and to help you process those. Not to give you pat answers but to listen deeply and kind of walk with you in a sort of friendship way of struggling through those questions as faithful companions, and a chance to do good in the world – a place where you could make amends in some ways for something that is all out of kilter in your life, that you feel that if you destroyed so much that you could actually help construct something positive. And those are all things I think religious communities understand. So we've made our mission at the Soul Repair Center training communities – not just religious communities, but veterans' groups, employers and others, in how you do this walking with someone through the process of recovery from moral injury. We don't want to stigmatize moral injury as some kind of disorder or problem; I think it's actually a fairly normal response to life or death conditions that are extreme and anguishing, and where a moral choice isn't clear. It's a social responsibility, our responsibility as a society to take this on, because we've sent these people to fight in wars on our behalf – whether we support the war or not, that's what they've done – so I think we all have a responsibility to support the process of their returning to us.

Rita Nakashima Brock is the founding co-director of the Soul Repair Center at Brite Divinity School in Fort Worth, Texas. Her latest book is titled, “Soul Repair: Recovering from Moral Injury After War,” co-authored with Gabriella Lettini. Find more information on moral injury at britesoulrepair.org.

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