Navy Medicine Perspective: Moral Injury

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By Lt. Cmdr. Miller Kerr, MD, psychiatry resident and Lt. Cmdr. Mathew Rariden, staff psychologist at Naval Medical Center Portsmouth

Wounds of war are not always physical – they can be psychological, moral and even spiritual.

Service members can be injured on many levels. One level less frequently mentioned in the literature is moral injury. In a combat zone, service members are often confronted with situations that are radically different from any experience they have had prior to military deployment. A moral injury may stem from ethically challenging or life and death situations that are completely different from one’s previous experiences. These ethical dilemmas and difficult experiences cannot always be processed and incorporated into one’s existing belief system. As a result, the individual may struggle with resolving the conflict between their pre-deployment values and beliefs, and their experiences and actions in combat.  This internal conflict and the associated feelings of anger, shame, betrayal and grief are referred to as a moral injury.

It’s important to note that the presence of moral injury does not mean a service member actually behaved “immorally.”  Feelings of guilt, doubt and shame following combat are not uncommon, and have little to do with one’s actual behavior.  Rather, moral injury can stem from the mere perception of behaving inconsistently with one’s beliefs, or the mere doubt that one behaved morally or ethically.  Service members contending with a moral dilemma of this nature often face challenges of the mind, body, and soul. They may therefore operate with diminished functional capacity, and the struggle that originated on the battlefield may follow them home.  It is not uncommon for service members who are attempting to re-integrate with their families and society post-deployment, to experience interpersonal problems and conflicts of faith. They may be unable to resolve fundamental questions related to values, interpersonal trust, and their life’s purpose.  Without guidance and support, the consequences can impact the service member’s relationships with family, friends and supportive networks.  Such injuries may also lead to problems in the workplace. To make matters worse, typical treatment pathways are not necessarily geared to address moral injuries as a distinct issue.

Moral injury is as old as war itself, but the tools and strategies to aid recovery are continuing to evolve.  The military has therefore focused significant resources to better understand moral injury and the context for healing.  Military medicine,  Chaplain Corps, research community and leadership at all levels have joined in this effort.  New forms of therapy for moral injury are being explored, and moral injury as a concept is increasingly being discussed in military treatment facilities. For example, Naval Medical Center Portsmouth has a specific Warrior Recovery Division with an array of treatment options to help service members better understand and resolve their unique post-deployment conflicts. Additionally, Naval Medical Center San Diego has programs that include complementary/alternative medicines and a variety of recreational therapies.

The key is working collaboratively with the service member to identify the most efficacious intervention for them and their family members. One important lesson learned over the past decade is the importance of guiding service members to develop a help-seeking mindset, starting at the earliest opportunity.