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The hidden, but destructive, injuries of war

This article first appeared in the St. Louis Beacon, Sept. 19, 2012 - “What is it about war that wrecks people?” Dr. Jonathan Shay says he knows the answer. When people are sent to war, they are put into mortal danger. When they get home, they remember what mortal danger on the battlefield looks like. This is the primary psychological injury veterans suffer.

“It is simply the persistence into civilian life of those valid adaptations to that real situation of a bunch of people trying to kill you and doing a damn good job of it,” he says.

Shay is a retired VA staff psychiatrist and recipient of the MacArthur Foundation “genius award” for his insights on the psychological impact of war. He spoke last spring at the Paul Simon Public Policy Institute on the campus of Southern Illinois University at Carbondale.

Shay says veterans recall their adaptations to battlefield danger in great detail, which he terms “hyper-remembering.”

“Hyper-remembering” results in a cluster of symptoms, such as intrusive thoughts, repetitive combat nightmares and occasional flashbacks, he says.

Shay says another set of symptoms occurs when veterans shut down activities of the mind, body, heart and emotions that don’t directly help them survive mortal danger.  These are known as the numbing and avoidance constellation of symptoms.

Then, Shay says, there is the enormous mobilization of the body and the mind to meet this perceived mortal danger.

The combination of these symptoms causes sleep deprivation, which Shay says, is the greatest danger to a veteran with post-traumatic stress disorder.

Lingering effects of moral injury

Moral injury is another common psychological problem a soldier faces, Shay says. By moral injury, Shay is talking about what other experts call trauma.

“My meaning is when there’s been a betrayal of what’s right by someone who holds legitimate authority in a high-stakes situation,” he says.

Shay says in a war time situation, the authority can be a commander who violates the ethical code of that community of people, such as a platoon, and someone is injured or killed because of that violation.

Shay says he was told of a Marine sniper whose mission was to kill an enemy sniper who had a baby strapped to him. The American sniper understood his duty to his fellow Marines was to kill the enemy sniper, even though it meant that the baby would be killed. So he took the shot.

Part of the horror of some military specialties, such as snipers and helicopter door gunners, is that they see the people they kill, Shay says.

“This Marine will live with this knowledge for the rest of his life.  It was entirely a legitimate and necessary thing that he did, but that doesn’t necessarily help.  He will probably live with moral injury in that sense,” he says.

Shay says moral injury destroys the capacity for trust and what is left in the combat veteran is an expectation of exploitation and humiliation.

“People who suffer moral injury just get deeply disconnected from other human beings and all possibility of a flourishing human life is lost,” he says.

Nancy Sherman, a professor of philosophy at Georgetown University and the U.S. Naval Academy’s first distinguished chair in ethics, says she frequently speaks with combat soldiers about their psychological injuries in her work as a moral ethicist.

One soldier was an Army major trained as an infantryman.

He was ordered by his commander to deliver solace money to the uncle of several family members who were accidentally killed by American troops killed during crossfire. 

When the uncle opened the envelope, he discovered the paltry sum of $750 inside and flung the envelope across the room. The major told Sherman he was consumed with shame and guilt.

Sherman says she spoke with another soldier about the guilt he felt after some of his troops were killed during a street battle in Iraq while he was on leave in Qatar. 

The young sergeant thought he could have prevented the deaths because he was more familiar with the layout of the buildings in the area where the failed operation had occurred, she says.

Sherman says the sergeant told her, five years after the failed operation, that he’d been consumed with guilt initially but eventually he realized he couldn’t always protect his troops.

His guilt was productive and served to let him sort through his emotions, Sherman says.

“Guilt isn’t just a compulsive disorder.  It isn’t just an irrational self-flagellation,” she says.

Understanding guilt is an important aspect of empathy, Sherman says.

She says in the past three decades "self-empathy" has become a hot topic in moral psychology, both from a philosophical and psychological point of view.

Sherman says Heinz Kohut, an Austrian-born Chicago psychotherapist, developed the theory of "self-empathy" in which a person bears compassionate witness to another’s pain.

Kohut’s components of "self-kindness" and self-respect play key roles in psychotherapy used to treat troops suffering from post-traumatic stress today, she says, adding that many soldiers eliminate the word “disorder” because of its negative connotation.

By using methods of therapy involving "self-empathy" and its components of "self-kindness" and self-respect, the soldier can let himself off the hook and more clearly distinguish between what he could have done in a situation and what he should have done, Sherman says.

"Self-empathy" allows the soldier to put distance between him and the traumatic incident without disassociating himself completely, she says.

Sherman says she often relates her philosophical studies of the Greek Stoics to her work with psychologically injured soldiers.

“The aspiration of a Stoic is to become a sage, and when you become a sage you leave behind the vulnerability of this world and you rely on your virtue instead of reason,” she says about the earlier Stoics. “That’s not the kind of distance from a former self that I’d advocate.”

“Forgiveness is an attitude of foreswearing anger. You are going to foreswear anger against yourself for having done something wrong to yourself, or to another, where you take responsibility,” Sherman says.

However, in most cases, she says, the individuals did not do anything wrong.

“Many of the soldiers, sailors, airmen and women, marines, did not do wrong. They did not violate just conduct. They did not act dishonorably. They were not disobeying just orders,” she says. “They just fell short because luck called them out. Or perhaps they had good luck. They came home and their buddies didn’t. And now they’re on a plane, and their buddy is not there.”

Sharon Wittke is a student as in the School of Journalism at Southern Illinois University at Carbondale. She served 25 years in the United States Air Force before retiring last year as a lieutenant colonel. These stories are part of a project of Midwest journalism schools, the Investigative Journalism Education Consortium.  For other stories in this series, see IJEC.org.