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A New Theory of PTSD and Veterans: Moral Injury


Thursday, December 13, 2012

A New Theory of PTSD and Veterans: Moral Injury

by Tony Dokoupil Dec 3, 2012 12:00 AM EST


Soldiers are supposed to be tough, cool, and ethically confident. But what happens when they have seen and done things that haunt their consciences? New studies suggest that the pain of guilt may be a key factor in the rise of PTSD.

They called themselves the Saints and the Sinners, a company of Marine reservists from the Mormon land of Salt Lake City and the casino shadows of Las Vegas. They arrived in Baghdad a day before Iraqis danced on a fallen statue of Saddam Hussein, and as they walked deeper into the city, they accepted flowers from women and patted children on the crown. Then their radio operator fell backward, shot in the head

In a series of pioneering studies, one researcher found that, from World War II to today, killing was the single greatest risk factor for PTSD, bigger even than heavy combat. (Alex Majoli / Magnum for Newsweek)

Perhaps 5,000 rounds followed in an undulating crosscurrent of gunfire and rocket-propelled grenades. At a five-point intersection near the headquarters of the Republican Guard and Defense Ministry, the men of Fox Company—Second Battalion, 23rd Marine Regiment—dug in. They aimed at everything, because everything seemed to be aiming at them. From second-story windows and around corners, they fired into the road. Their bullets broke windshields, pierced soft flesh, and exited into seat cushions. At least three enemy vehicles broke through the American barricade. The company’s radio failed, cutting them off from reinforcements, and a grenade bounced behind their line—a dud, or the casualties might have been even worse.

Although all the men in the unit came home alive, many came home changed. Within five years, one in four had been diagnosed with posttraumatic stress disorder. Today one in two of them carries debilitating psychic wounds, according to an estimate by the men. They are jobless, homeless, disposed to drugs and alcohol, divorced from their spouses, and cut off from their former selves. One made love to his girlfriend, the mother of his twin daughters, then immediately drowned her in a warm bath. If you ask the military and mental-health establishment what happened to the men of Fox Company, the answer is simple: they lived through “events that involved actual or threatened death,” felt “intense fear,” and like the 300,000 other service members who share this narrow official path to PTSD, they were badly shaken by it.

But as clergy and good clinicians have listened to more stories like these, they have heard a new narrative, one that signals changes to the brain along with what in less spiritually challenged times might be called a shadow on the soul. It is the tale of disintegrating vets, but also of seemingly squared-away former soldiers and spit-shined generals shuttling between two worlds: ours, where thou shalt not kill is chiseled into everyday life, and another, where thou better kill, be killed, or suffer the shame of not trying. There is no more hellish commute.

When they came home from the war, members of the Fox Company brought the fear with them, according to the conventional view of PTSD. They tried to stuff it, marriages exploded, careers disintegrated, and then a door slammed, or a kid shrieked, and they were back in the intersection, a sweaty, palpitating mess. Since PTSD entered the pantheon of official disorders—at first it was called Post-Vietnam syndrome—this “fear-conditioning” model has pushed out all others. It was developed by shocking lab animals, then soothing them back to some level of normal squeaking and scratching.

And for many veterans, the resulting treatments—a pill, a course of talk therapy—work just fine. But despite three decades of research and billions of dollars in government funding, America’s servicemen and -women are not getting better. They are getting worse. Self-harm is now the leading cause of death for members of the Army, which has seen its suicide rate double since 2004, peaking this past summer with 38 in July alone. But the risk to discharged veterans may be even greater. Every month nearly 1,000 of them attempt to take their own lives. That’s more than three attempts every 90 minutes, at least one of them successful. Every time the credits roll in a movie, or the postgame show begins, another veteran is dead. “It’s an epidemic,” Secretary of Defense Leon Panetta admitted to Congress this summer. “Something is wrong.”

Military leaders have pointed to alcohol, guns, and girl trouble. The secretary of Veterans Affairs recently suggested wider societal woes, noting that suicide is up for all young men and women. But new ideas are vying for legitimacy, a whole new theory of war’s worst ravages. It’s called “moral injury,” and it comes from clinicians who spend their days speaking with soldiers who have been in battle. These veterans rarely mention fear. Instead they talk about loss or shame, guilt or regret. They had tried to be heroes, to protect the weak, save their buddies, take the hill. But then they mistakenly killed civilians, forced themselves to drive past wounded children, sometimes missed their moment of truth. Even after the Battle of Fallujah, in 2004, where William Nash served as a combat psychiatrist, fear wasn’t a factor. “Survivor’s guilt, moral injury, feeling betrayed by leaders,” says Nash, the lead author of the current Navy and Marine doctrine on stress control, “That’s what I saw every day.”

Now, along with some of the most distinguished doctors in the Department of Veterans Affairs, he believes that moral injury and its sister, traumatic loss, may be the “something” Panetta is looking for: the leading cause of PTSD, depression, substance abuse, and even the military’s epidemic of suicide. If so, it’s a radical idea. It shifts the focus onto what service members do to others, or in some cases fail to do for each other—not what gets done to them. Perhaps most controversially, it allows for the fact that war itself, no matter how just or good, will leave many of the men who fight it feeling like they’ve dirtied their souls, and perhaps for a simple reason: there is just something about killing that bites the conscience and doesn’t let go. “I don’t want to use it as a crutch,” former lance corporal Walter Smith, the member of Fox Company who murdered the mother of his children, said in a prison interview in 2008. “But I know for a fact that before I went to Iraq, there’s no way I would have taken somebody else’s life.”

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