PTSD, Moral Injury, and the Church’s Call to Respond

The category “moral injury” is not yet recognized as an official diagnosis in the 2013 Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. Neither is it so recognized by the Department of Veterans Affairs (VA). While the manual has added guilt and shame as symptoms of post-traumatic stress disorder (PTSD), the focus of treatment for such remains on fear.

A new narrative is seeking to be heard as a voice in the cause and need for treatment of PTSD: moral or soul injury as a result of participation in war. The rise in self-harm—last year active duty suicides reached an all-time high of 349, according to Associated Press, and there were more deaths from suicide than combat—justifies Defense Secretary Leon Panetta’s use of the term “epidemic.”

Military psychiatrists listen repeatedly to stories of survivors’ guilt, participation in the deaths of civilians, and the confrontation with corpses. William Nash, who worked with many following the 2004 battle of Fallujah, contravening the prevailing diagnostic wisdom, said that fear was not a factor. In his continued work with VA, Nash believes that moral injury and traumatic loss underlie much of the stress syndromes crying out for care and treatment.

The key to this is shifting from what has happened to persons to what they either did or failed to do for others. That sense of failure (inability to save a comrade) requires sustained exploration. Surviving a friend in combat can cause more severe grief symptoms than surviving the death of a spouse, even up to thirty years later. Understanding the relationship between soldiers who have lived through combat is intrinsic to understanding why such a loss is an injury to the soul, laced with feelings of betrayal and guilt. Adding to the complexity is the moral question raised by veterans about the issue of killing, which Nash and other VA clinicians explore in their article “Moral Injury and Moral Repair in War Veterans” (Clinical Psychology Review, 2009).

What can the church do to minister to those suffering from PTSD and moral injury?

1. The church should enter into conversations with those who speak of soul injury and moral injury. Brite Divinity School of Texas Christian University has opened the Center for Soul Repair, which is dedicated to research and education.
2. When ministering to veterans with forms of PTSD and moral injury, be careful not to speak of a dismissive spirituality such as “Jesus is the answer.” Rather, do we have the courage and the patience, like Jesus, to ask, “What are your questions?” Can we guarantee a listening presence, not a hasty retreat? Jesus was Immanuel: God with us. That is our first vocation: to be with the seeker.
3. Since guilt is involved, the presentation of the atonement is to be made in such a manner that persons can make a full disclosure of their lives without fear of the listener passing judgment. Likewise, the atonement is not to be presented in any such dismissive fashion so as to minimize the person’s desire to seek full integrity. “Atonement” carried the meanings of “covering and purging” sin by the blood of the lamb, but it never implied a “cover-up.” God provides a covering for anyone who wants to “come clean with their lives.” God leaves none exposed. But the pursuit of integrity—the integration of a once fragmented life—is not to be easily dismissed.
4. Be prepared for tough questions, such as regarding killing, without seeking to change the subject, criticizing the questioner, or pulling out of the relationship. Keep it a conversation. Ask permission to get outside resources when appropriate, but let the questioner know that he or she has full freedom to question.