MILITARY: Moral injury as a wound of war



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Military: 'Moral injury' as a wound of war

Conference to examine consequence of battlefield transgressions, exposure to carnage

MILITARY: 'Moral injury' as a wound of war Conference to examine consequence of battlefield transgressions, exposure to carnage

A group of mental health experts is giving a name to the guilt and remorse troops feel when they see or do bad things during war: moral injury.

They say failure to recognize and acknowledge exposure to military or civilian carnage in Iraq and Afghanistan sets up troops for post-traumatic stress, a severe and often debilitating anxiety disorder that affects 1 in 5 combat troops.

The experts' findings on the emerging war wound will be discussed at a combat stress conference May 18-20 in San Diego. A study of the issue was first published in December in Clinical Psychology Review. Moral injury is not now officially recognized as a mental health malady.

The principal author of the moral injury paper, Dr. Brett Litz, said he and his colleagues are calling for wide-scale research into the issue to validate its existence and how it may lead to post-traumatic stress.

"Moral injury can occur from what you witness or what you do," said Litz, a clinical psychologist, professor and counselor for the Department of Veterans Affairs. "I've been seeing veterans for 24 years, and when people who seem well-adjusted and doing fine really talk about their war experiences, what often emerges is sadness about the loss and what they saw. That is moral injury."

Litz and his collaborators specifically define a moral injury experience as "perpetrating, failing to prevent, bearing witness to or learning about acts that transgress deeply held moral beliefs and expectations."

They argue that service members who don't talk to loved ones, clergy or some other confidant will become convinced what they did is unforgivable, leading to recognized symptoms of PTSD, such as withdrawal, self-condemnation and avoidance.

Treating troops with moral injury, they say, requires a deeply caring and respectful therapeutic relationship and a dialogue with a "benevolent moral authority."

Treatment also should involve doing good deeds as a way to make amends.

"The lasting impact of morally injurious experience in war remains chiefly unaddressed," according to the experts.

The nature of insurgent wars, where the enemy blends in with the population, exacerbates the normal stresses associated with combat, they contend.

"The current wars may be creating an additional risk for exposure to morally questionable or ethically ambiguous situations," they write. "Many service members may mistakenly take the life of a civilian believed to be an insurgent, be directly responsible for the death of enemy combatants, unexpectedly see dead bodies or human remains or see ill or wounded women and children who they are unable to help."

The presentation at the U.S. Naval Center's Combat Operational Stress Control conference represents the first official unveiling of moral injury as a war wound.

This is the second time the conference has been conducted in San Diego. It draws hundreds of Marine and Navy officials and dozens of clinicians charged with monitoring and treating troops suffering from post-traumatic stress, traumatic brain injury and related consequences of America's two wars.

Roughly 20,000 Marines among the approximately 300,000 that have seen action in Iraq and Afghanistan have developed PTSD, according to the center. About 60,000 have suffered mild traumatic brain injury as a result of repeated exposure to explosions.

The mental health and support needs of families of service members also will be addressed at the conference as the Marine Corps continues to see a rise in its suicide rate.

The number of Marines taking their own life has spiked from about 13 per 100,000 in 2006 to 24 per 100,000 now. Marine Corps officials said Wednesday that a Camp Lejeune corporal who worked in public affairs at that North Carolina base is believed to have committed suicide when he was struck by a freight train traveling through the base.

The highlighting of moral injury comes after thousands of locally based Marines have deployed to Afghanistan, where civilian casualties are rising as that nearly 9-year-old war shows few signs of being resolved.

Many of those Marines are on their second, third or fourth combat deployment, and studies have shown that despite their training, troops subjected to repeated combat deployments are more likely to be involved in what Lisk and his co-authors call "wrongful acts."

A field survey of soldiers and Marines conducted in Iraq in 2006 found that 17 percent believed all civilians should be treated as insurgents, according to Litz and his colleagues.

They also cited a similar study conducted in 2007 that found that 31 percent had insulted or cursed at civilians, 5 percent acknowledged mistreating civilians and 11 percent admitted unnecessarily damaging private property.

Formally recognizing moral injury as an issue and a precursor to PTSD is long overdue, according to Bill Rider, president of the Oceanside-based American Combat Veterans of War and a counselor to troops haunted by their combat experience.

"It is absolutely a forerunner to PTSD," Rider said. "We have a lot of young men and women who are angry as a direct result of what they saw and did in the war and far too many don't know what to do about it. The services need to address this and it needs to be validated."

Moral injury has always been a part of war, Rider said, and is often dismissed by military commanders.

"All you have to do is look at history," he said. "Look at how many Vietnam veterans killed themselves. We have a lot of Marines now who get into trouble because of aberrant behavior when they come home and it's often attributed to them being 'bad Marines' when in fact it all stems from the moral injuries that happened to them."

Call staff writer Mark Walker at 760-740-3529.


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