Revealing the hidden trauma of moral injury
Troy Parson was a teenager when he sensed a call to become a military chaplain. His father was a U.S. Army nurse, and Troy grew up attending base chapels, which offered various ministries and group studies. He saw the positive influence chaplains had on the life and moral development of the community, and he hoped to make a similar impact. When he finished his studies at Bethel Seminary in 2005, he joined the Army. In 2006, the infantry battalion he served was among the 30,000 troops sent to Baghdad as part of the surge to quell the bloodiest sectarian violence of the war. By the time he left Iraq in 2008 he felt betrayed by his commanders, by God, and by himself.
Part of the surge strategy was for troops to live amid the Iraqi people. “We lived in an occupied house in the community,” Parson says of his time in Baghdad. “It was fortified by guards on the rooftop, and concertina wire surrounded the perimeter. There were daily attacks. I practically lived inside my body armor.”
His initial commander believed in the mission and wanted to help the Iraqi people, Parson says. “He had a big heart and really wanted to help the people we were fighting for. He was a true hero.” After just a few weeks, however, the officer was seriously injured by an improvised explosive device. His replacement was a different kind of person.
Parson says the troops did not receive the equipment they needed. They were sent on seemingly unnecessary missions that resulted in serious injuries. “We’d be out on patrol for days at a time instead of 12-hour shifts, stretching the guys so thin. It pushed people past breaking,” he says.
In his role as chaplain Parson also participated in duties as a religious leader liaison, collaborating with local religious leaders such as tribal sheiks to generate support for the efforts to subdue insurgents. Those efforts were “absolutely unsuccessful,” he says. The local leaders were fearful of both the coalition forces and the insurgents themselves. “The leaders who did give us support were executed,” Parson says.
Soldiers were not permitted inside mosques, so Parson was ordered to provide intelligence reports from his interactions as chaplain. “I was put in the position of having to risk my career by breaking the noncombatant rules of engagement. And by sharing intel, I was breaking trust with the people I was befriending. If the unit took action based on my intel, they would know the information came from me.”
He had hoped to provide ethical guidance to commanders seeking to make moral decisions. But his commander didn’t want his input. Looking back on his experience in combat, Parson says, “I’ve had fire directed at me—rockets, IEDs. But that wasn’t the worst part. The worst part was our commander. That’s the betrayal.”
Parson also felt like he was failing the soldiers he was supposed to help. He felt responsible when they were injured and when they died. He began to suffer depression that continued to worsen. “You feel lethargic, no energy, there’s anger. You’re just waking up to do what you need to do and then lie down again.”
A person’s religious convictions may either contribute to their experience of moral injury or they can lead to healing.
Although he didn’t name it at the time, Parson came to feel betrayed by God for all the brutal deaths he witnessed. “I saw people whom I considered to be saints just mutilated. There was so much of that. It was heaped and heaped on top of that. It seemed like it was never going to end. It was a daily barrage of pain. It wasn’t just anger but also a depletion of hope.”
Then he came home.
“I was a different person. No one wanted to hang out with me,” he says. “I had zero patience. I was yelling at my kids and getting upset about the smallest things. I had all this anger built up, and I didn’t know what to do with it.”
Parson was reluctant to get help because of the stigma attached, he says. “No one thinks chaplains experience combat,” he explains. “They think we are somehow unaffected.”
But those unnamed wounds continued to fester. His relationships suffered. He was increasingly defensive toward his commanding officers. Eventually, he says, “I disrespected the wrong person,” and the army issued him an involuntary separation.
That’s when Parson got serious about seeking assistance. “I didn’t have to worry any more about what my boss thought, so I felt free to get help,” he says. “It was actually a relief.”
IN THE FIRST HALF of the 20th century the damaging effects of trauma on soldiers were identified with terms like shell shock and combat fatigue. It wasn’t until 1980 that the American Psychiatric Association included PTSD (post-traumatic stress disorder) in its manual of mental disorders, defining it as “a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, rape, or other violent personal assault.”
Although the PTSD diagnosis “filled an important gap in psychiatric theory and practice,” according to the U.S. Department of Veterans Affairs, mental-health professionals began to recognize that PTSD was not a large enough umbrella. Soldiers were experiencing trauma that seemed beyond the scope of that definition. Psychiatrist Johnathan Shay was doing extensive work with combat veterans, and in 1994 he coined a new term for the trauma they were experiencing: “moral injury,” which he defined as “a betrayal of what’s right, by someone who holds legitimate authority, in a high stakes situation.”
Experts explain that whereas PTSD is rooted in fear, moral injury stems from shame.
A decade later, psychologist Brett Litz, who has served as the principal investigator on multiple research projects funded by the Departments of Defense and Veterans Affairs, expanded on Shay’s definition, calling moral injury the “psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.
”Experts explain that whereas PTSD is rooted in fear, moral injury stems from shame. Sufferers of moral injury often feel guilt, anger, an inability to trust, and a profound sense of betrayal by others, especially when someone in authority forces them to act in a way that violates their conscience. It can lead to depression, substance and physical abuse, and suicide.
“People who have suffered a moral injury often feel that they’ve crossed a line that they can’t uncross, and they don’t know what to do about it,” says Navy chaplain Lieutenant Commander Jason Ulven. “It’s over a prolonged time of being in combat, of seeing death.”
Drone pilots, who attack enemy combatants from bases in the United States, experience moral injury in a unique way, says Ulven, whose postings have included Naval Special Warfare, the Coast Guard, as well as with a Naval Aviation Wing. “They’re nowhere near the combat or being threatened in any way. They’re here in the U.S. and they’re dropping ordnance on people in Afghanistan,” he says. One retired drone pilot wrote in a letter to the New York Times, “I’d literally just walked out on dropping bombs on the enemy, and 20 minutes later I’d get a text—can you pick up some milk on your way home?”
Moral injury is nearly impossible to identify in the midst of combat, say chaplains and researchers. “Military service members do a great job of wearing a courageous mask and pretending that everything is all right,” Ulven says. “It generally rears its head when someone makes a suicide attempt or has an alcohol-related incident. Then they begin to share their burden when they’re directed to a chaplain.”
Although some people experience the pain of moral injury shortly after a specific incident, most don’t until much later, chaplains say. Parson explains that in the midst of a war zone, troops often have to compartmentalize their feelings in order to do their jobs—and survive.
Moral distress is the leading reason
nurses leave a specific job or
their profession altogether.
ALTHOUGH MOST RESEARCH ON MORAL INJURY has been done among the military, the concept is being applied to other settings as well. “Moral injury afflicts ordinary moral people, when no good choice is possible in situations where people must use the power they have to act, knowing they will cause harm, or violate their own core moral values,” according to the Shay Moral Injury Center.
There is no set definition for moral injury, and some researchers differentiate between moral injury and “moral distress,” a term first used by nursing ethicists in 1984. The distinction is that moral injury is related to violence and death-related incidents, whereas moral distress is related to situations in which the person feels prevented from doing what is right.
Moral distress is the leading reason nurses leave a specific job or their profession altogether, says Karla Fogel, a recently retired nursing professor from North Park University who wrote her doctoral thesis on identifying moral distress and its impact on staff.
Events that cause moral distress include not being able to provide what a nurse believes to be appropriate care, such as administering effective pain medication. Or it may mean continuing an invasive yet painful treatment to keep someone alive at the end of life. “Then you have to be there and watch them suffer,” Fogel says.
Physicians also may feel constrained by health insurance, institutional restrictions, as well as patients and their families, that prevent them from providing what they consider appropriate care. Medical professionals commit suicide at a rate that is second only to the military, says the American Medical Association.
Redemption for someone with moral injury is not a onetime event but a process lived out in faithful communities of care.
Parson says a person’s religious convictions may either contribute to their experience of moral injury or they can lead to healing. “Maybe you grow up thinking you aren’t supposed to question God, or maybe you believe God pre-ordains everything that happens,” Parson says. “But if God has ordained everything, why did God intend these horrible things to happen? If it’s God’s fault, how can God love me? If something happens to me, or my buddy Joe gets hit by an IED, how can I forgive God for that?”
Theologian Rita Nakashima Brock, who guides the Soul Repair Center at Brite Divinity School and helped launch the Shay Moral Injury Center, says that religious institutions and communities must be willing to journey appropriately with people who have suffered moral injury.
“We must understand that respect for veterans requires us not to patronize them by trying to be their therapists—we do not hold the key to their redemption,” she writes in Soul Repair: Recovering from Moral Injury. “It is not for us to forgive them but to help them find ways to forgive themselves and to let them know their lives mean something to us and to others. Finally, we must be willing to engage their moral and theological questions with openness and to journey with them as we are mutually transformed in the process.”
The authors of a Baylor University paper on recovering from moral injury wrote that Christian community “should not seek to present a false dichotomy, choosing either moral injury or hope. Rather, it should seek to present an ‘and’—moral injury and hope, and trust, and meaningful relationships. In this fashion, redemption for someone with moral injury is not a onetime event but a process lived out in faithful communities of care.”
Ulven emphasizes the need to listen without judgment. “I often try to get people to separate the things they can control from the things they can’t control,” he says. “So often, they feel guilty about the things they can’t control. Those are some of the hardest things to let go of.”
TODAY PARSON WORKS AT Jonathan M. Wainwright Memorial VA Medical Center in Walla Walla, Washington. He took the position after earning a DMin and writing his dissertation on “Examining the Efficacy of Pastoral Care with PTSD Patients.” He says being able to talk with others has helped him on his own journey. “I’m at a more logical place. I can see that I did the best that I could with what I had and that it’s OK to make mistakes.”
