Invisible injury

January 30, 2019 by Sharon Adams

If a soldier’s moral conscience is damaged, the problem and the solution can both be hard to find

 

Robert Carter

For almost a decade, Canadian Armed Forces reservist James (not his real name) has been haunted by memories from one of his three tours to Afghanistan—haunted by something he did not do. 

An Afghan civilian reported to him that a member of the Taliban had set an improvised explosive device (IED) along a route travelled by patrols returning to base. The informant said he could see the terrorist lying in wait, ready to blow up the next military vehicle to come by.

Although he was in radio contact with a Canadian convoy using that road, James had been ordered to pass such information only up through the chain of command, where it would be verified and orders issued. He was warned that charges would be laid against anyone who passed along information otherwise. “They said, ‘We’re a unit, one organization…the information is going to come from us, not you as an individual.’”

So, that’s what James did. Sent the information up. “And waited, and waited, and waited.”

Then over the radio came words he dreaded to hear: “Contact IED.”

“I heard the second-by-second, minute-by-minute update.” Heard the reports as ammunition in the LAV started to cook off. Heard the desperate comments of comrades in failed rescue attempts.

“I’ve always questioned if that delay, because of people’s egos, because of following rules, if that cost lives…in situations like this, in situations of life and death, fuck all that, none of that matters.

“I have to live with that every day. Every time I see these guys’ pictures in the news, every time I remember that tour, it affects me. Those guys would possibly be here and aren’t because I followed the rules. I obeyed the orders. I have that guilt.”

James is still serving and asked not to be identified in this article. Although he has been treated for post-traumatic stress disorder, those unextinguished feelings of guilt are a hint of a different kind of injury, one as old as armed conflict.

Moral injury. It’s an injury not to the body, not to the mind, but to the inner self, the conscience or moral compass—some say the soul or spirit.

Moral injury can coincide with a post-traumatic stress injury, but it can be altogether separate. Not everyone who has PTSD also has a moral injury and conversely, not everyone with a moral injury has PTSD. But some people suffer both.

Veterans with moral injury can be haunted by something they did not do, as in being unable to rescue someone or intervene in wrong-doing—or something they did do, such as having to choose which life to save, or accidentally killing an ally. It can be caused by witnessing or learning about an act that goes against deeply held beliefs, such as the killing of civilians or children, a massacre, or enemy execution of a helpful civilian.

And it can be caused by betrayal of deeply held beliefs—lives unnecessarily sacrificed; orders violating rules of engagement, military ethical codes or the Geneva Convention; a devastating lie from a source who should be entirely trust-worthy; dishonourable conduct.

“One of the most frequent causes of soul injury is betrayal,” said Vancouver psychologist Marv Westwood. Feeling abandoned by comrades or chain of command when ‘I’ve got your back’ is a mantra of service; being shamed and shunned by the very people they were willing unto death to serve.

Over the years, Legion Magazine has interviewed many veterans who have suffered moral injuries. A sniper in Croatia in 1993, who helplessly watched the massacre of an entire village, but was prevented by rules of engagement from intervening. A submariner who survived the fire on HMCS Chicoutimi in 2004, and felt sailors’ lives were held cheap by command and survivors’ health needlessly endangered.

One young soldier during the October Crisis in 1970 had his faith in the military and his own moral compass shaken by a warning that he could be ordered to shoot fellow citizens, leading him to question, even now, whether he would have pulled the trigger.

A female soldier in the early 2000s was shamed into feeling guilty and disloyal for reporting sexual assault by an officer in garrison, while also feeling violated by the assailant, whose duty it was to protect her, as well as the chain of command that belittled her.

Shame and guilt are hallmarks of the injury, negative emotions that become life’s background noise, an earworm of intrusive thoughts, a combination of memories and self-condemnation looping through the mind. They lead to self-medication with drugs and alcohol and other actions described in psychology literature as “parasuicidal behaviour.” People can become so demoralized they reject anything that might raise the spirits, so hopeless and suspicious they can trust no one. Shame and guilt lead to many attempted—and too many successful—suicides.

Moral injury violates core beliefs about what is right and wrong, good or evil, just and unjust. It goes far beyond hurt feelings, to the anguish of dark nights of the soul.

“The profession of arms is profoundly moral in nature,” said Megan M. Thompson, a research scientist with Defence Research and Development Canada. From a government’s decision to deploy to an army’s strategic plan to the actions of an individual soldier manning a gun—decisions at all levels involve justice, fairness and the right thing to do. “It involves high stakes, deeply held values and the well-being of others.”

Ethics separates combat and warfare from murder and slaughter—and demands a higher standard of behaviour from soldiers, sailors and air force members—on and off the job. Military professionals in Canada are guided by written rules and provided with ethics training. “Ethics is a fundamental principle of the culture of our men and women in uniform,” said Department of National Defence spokesperson Ashley Lemire.

DND’s Statement of Defence Ethics requires military members “at all times and in all places” to respect the dignity of all persons, serve Canada before self, and obey and support the law, acting with integrity, loyalty, courage and stewardship. That’s backed up by the Defence Ethics Programme Code of Values and Ethics, which requires members to behave “in a manner that will bear the closest public scrutiny.”

The code gives many examples, but says “expected behaviours are not intended to cover every possible ethical situation or issue that might arise.” It also encourages members to seek advice and support from “other appropriate sources within their organization.”

For 26 years, retired chaplain Jim Short was one of those sources. Moral injury “has been around since the beginning of time, the beginning of warfare,” he said.

But the term was not in use in the 1990s, at the start of his career, when the military was dealing with fallout from a peacekeeping mission during which a Somali citizen was beaten to death by members of the subsequently disbanded Canadian Airborne Regiment. Nor in Bosnia, where Canadian soldiers witnessed massacres, genocide and other atrocities; nor Rwanda, where they dealt with child soldiers. The 1990s brought attention to the need for ethics training, said Short. Coincidentally, it also marked the evolution of diagnosis and treatment of post-traumatic stress and preventive training.

But “when I went to Afghanistan, people were distressed, and it wasn’t related to a particular incident of trauma,” as with post-traumatic stress. Among the troubled souls were soldiers with moral and ethical dilemmas related to killing the enemy or who felt guilt and shame from celebrating insurgents’ deaths.

Chaplains are non-combatants, but go on deployments, sometimes accompanying troops even to forward operating bases to support and help those who come under fire. “We don’t carry weapons,” said Short. “And we don’t have the power of command. We’re the one profession that has equal access to all ranks. A troubled private can’t just knock on the door of a major and say, ‘Hey, I want to talk to you.’ But they can do that to a chaplain. We’re approachable.” They help all troops, regardless of denomination or religion, or lack thereof.

Chaplains are experienced in determining the needs of those who’ve been through moral trauma, and are often the first step to wellness for the morally injured. “You cannot simply quote the ‘just-war’ theory to them. Sometimes they need to connect to their religious roots or they may need to talk about their concept of good and evil and God. They may need to be connected with other people who have gone through the same thing.” Short knows this from personal experience: he himself has suffered a moral injury and is being treated for post-traumatic stress.

Many chaplains have therapeutic training, work in mental-health clinics or as part of a mental-health team. “A really important function is to identify and refer.”

Confidentiality is key. “Troops know that if they go to the medical people, things are going to start to be written down.” Chaplains recognize that “they may be having a struggle, but are able to function fairly well, so we don’t want to make them a casualty,” either on deployment, or once they return home.

But what can and should be done to help those with moral injury? Clouding the issue are disagreements about what moral injury is, how it should be treated, whether it is preventable, whether it’s a leadership issue, a legal issue, or a spiritual issue best handled by chaplains, and what is the most effective method of ethics training. Research provides few answers, particularly in Canada, with its smaller military and pool of scientists.

Evidence-based methods of prevention and treatment are slow in coming, because there is, as yet, no diagnostic criteria for moral injury. Some argue there never should be, because it is not a medical condition.

“The problem is, what can you do to treat and prevent it when it hasn’t even been defined yet,” said CAF senior psychiatrist Colonel Rakesh Jetly. “There’s a risk of putting a medical model onto something that may not be an illness. That doesn’t mean people aren’t suffering. But it may be premature to call it an illness when it may just be a distressing part of the human condition.”

Some people believe moral injury is a disease unto itself, others that guilt and shame are a complicating factor of another disease or condition, such as PTSD. “Some believe it may explain why a lot of people don’t get better with traditional [PTSD] therapy,” said Jetly. Recent U.S. research documented that while most patients showed improvement of symptoms, two-thirds still met the criteria for PTSD diagnosis after treatment with the two most widely used therapies.

Some argue that PTSD treatments involving repeatedly recalling the trauma in order to normalize the fear reaction may actually worsen the shame and guilt of a moral injury. Others report success in adapting PTSD therapy for those with moral injury.

DND and CAF are heavily involved in international research to define military moral injury, establish a way to measure it, identify potentially morally injurious events and facilitate prevention and treatment. Research so far has established a relationship between ethics, morality and mental health, said Jetly. Having mental-health issues raises the risk of moral injury, and moral injury can cause mental-health problems.

As the international military debate goes on, as researchers try to make sense of it all, soldiers, sailors and air force personnel are dealing with the effects of moral injuries and the situations that give rise to them.

Data from the 2013 Canadian Forces Mental Health Survey shows 58 per cent of personnel deployed overseas between 2001 and 2013 were exposed to events that heighten risk of moral injury; 39 per cent were unable to help injured women or children; 32 per cent felt responsible for Canadian or allied personnel; six per cent had difficulty distinguishing civilians from combatants.

“We ask our soldiers to make ethical decisions under circumstances that can—but do not always—affect moral decision-making,” said Thompson. Aside from operational stressors—harsh weather, rough living conditions, sleep deprivation, hunger, thirst, fear—military personnel, including junior ranks, have to make quick decisions under great stress and often with insufficient information. The right thing to do may not immediately be clear. One set of values may violate another and a negative result will happen regardless of action taken, or inaction. The mission may have several competing and incompatible goals—combat, area stabilization, a humanitarian component.

Modern conflict presents unique challenges, said Thompson. Insurgents don’t wear uniforms. They have moral codes quite different from western forces and play on those differences to provoke a disproportionate response or retaliation.

Those responses, and other ethical infractions and misconduct which lead to moral injury, can be curbed, reducing dishonourable behaviour and long-term mental-health problems, including suicide, said U.S. Army Colonel Christopher Warner at a NATO seminar on moral injury.

A decade ago, research found less than half of U.S. troops serving in Iraq and Afghanistan believed non-combatants should be treated with dignity and respect. A third described local populations in derogatory terms. One in 10 had damaged civilian property and five per cent had hit or kicked civilians. A third believed torture is acceptable to save a comrade. Less than half would report a team member’s unethical behaviour. “A reduction in nearly all levels of behaviour” followed the institution of ethics training, which included teaching leaders how to maintain ethics on the battlefield, said Warner.

Canada invests in career-long ethics training, said Lemire, including an ethics module for new recruits, annual ethics training, leader-led dialogue, briefings, awareness activities and scenarios. Its Road to Mental Readiness training is also geared to improve performance in the short term, and long-term mental health.

But nothing prepared Tim Garthside for the moral and ethical situations he faced in Afghanistan.

“The defining piece of soul injury is the depth of injury,” says Garthside, a signals operator during a day-long firefight in Panjwaii on Aug. 3, 2006, which took out an estimated 90 Taliban at the cost of four Canadians killed and at least 10 wounded.

Garthside’s job that long, long day was to relay messages to and from infantry in Panjwaii and CAF headquarters. His shift started with an IED incident.

“There’s people injured and one dead, but they’re taking fire,” he recounted. “Medevac will not fly in if they’re taking fire; they need a clear landing zone. I have in one ear the infantry asking for medevacs and in the other ear, HQ telling me that no one’s coming.”

Elsewhere in the battle, Taliban were being rooted out and eliminated in airstrikes directed by an onsite Afghan counterintelligence source. A pilot reported a man on a roof armed with a rocket-propelled grenade gun. Garthside asked command what to do, and relayed the kill order. “They cut him in half, and within five seconds, intelligence says their phone went dead. So, in effect, I killed a guy that was enabling us to save Canadian lives.”

At the end of his shift, an officer asked if he was OK. “I said I was fine,” Garthside said, something he continued to say for years. But he wasn’t.

Back home, he had trouble sleeping. “I wasn’t in the infantry and I wasn’t on the front line. I thought there’s no way there could be anything wrong with me because I didn’t get shot at or blown up.” Insomnia morphed into depression, physical and psychological pain, isolation from friends and family, self-medication with alcohol and drugs.

“It took six years for me to want to kill myself,” said Garthside. He received immediate support at a branch of The Royal Canadian Legion, where he met a veteran who referred him to a psychologist and the Veterans Transition Program, a peer group program which has helped hundreds of veterans with PTSD over the past 20 years.

“It 100 per cent saved my life at the time,” he said. So much so that he volunteered for the program, eventually participating in training videos involving therapeutic enactment. During one session, “I realized I blamed myself for the death of that Afghan man.” He calls it a soul injury. “The psychological pain was like that of being cut in half. And it ran to the very core of who I am.”

“The degree of pain they experience is tied to the degree of goodness,” said Westwood, co-founder of the program, which has been altered to accommodate those with moral injury. “Although the morally injured often see themselves as a failed person, their anguish actually proves how honourable they are.”

This program helped Garthside wrestle his demons, but there have been few randomized control trials comparing effectiveness of different treatments, no handy list of evidence-based therapies.

“In the end, it may be that there is no one right treatment that will be effective for all situations,” Thompson wrote in a CAF report. Since moral injury knows no borders, ideally a multinational, randomized control trial could identify best practices for the care of moral injury, which could be tailored for differences in national and cultural practices and individual clients’ needs.

Individualized support has helped Garthside turn his life around. He is working toward a degree in social work, and at press time was looking forward to becoming a father. He still sees a therapist weekly for PTSD, and is still coping with his moral injuries.

“There was literally nothing I could do but tell those guys no one was coming. In a way, I was betraying those guys. Even if it was headquarters that made the decision, I’m the talking head. And saying I did my job and I did my job well or whether it was a mistake, the reality is that Afghan man is dead. That’s the piece that beats your insides out, that still does.”

Still, he has a better perspective on it today. “I was acting for the greater good. I’m not healed, but I have so many more tools to cope. I have more depth of character to draw on. That shift in perspective allows me to re-engage with life. Instead of being in a live production, I’m looking at a picture.”

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