Moral injury among the issues facing combat veterans

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With suicide rates among veterans on the rise, another problem facing veterans also is capturing the public's attention. Service members suffering from moral injury are feeling profound guilt and shame for things they may have done — or not done — in combat, or for events they may have witnessed.

According to the U.S. Department of Veterans Affairs, “Events are considered morally injurious if they ‘transgress deeply held moral beliefs and expectations.’ Thus, the key precondition for moral injury is an act of transgression, which shatters moral and ethical expectations.”

While moral injury may sound similar to post traumatic stress disorder, there are marked differences.

“One very significant difference is that PTSD is a formal diagnostic term, a formal psychiatric disorder or ‘syndrome,’" said Leticia Flores, Ph.D., associate professor of psychology at VCU. “Professionals in the mental health field all know the criteria that one must meet in order to get a diagnosis of PTSD, and it is a recognizable condition that may be used to justify treatment, compensation, etc.

“The concept of moral injury is a much fuzzier, ethereal, existential state of being. Moral injury still tends to be thought of as falling within the realm of religion or philosophy. There is no ‘diagnosis’ called moral injury, so there are currently no commonly accepted, medicalized treatments or industry standards for compensation based on the condition. While PTSD seems to be most related to the fear response — it is considered an anxiety disorder — moral injury is considered to be more shame- or guilt-based.”

Flores is director of the VCU Center for Psychological Services and Development, a training facility for advanced counseling and clinical psychology doctoral students. The center partners with the Lewis B. Puller, Jr. Veterans Benefits Clinic at the College of William & Mary to assist veterans in receiving disability benefits.

The clinic, which receives no federal funding, has garnered interest from the federal level. Last year, members of Congress toured the facility, and legislators have referred their constituents looking for help to the facility. After First Lady Michelle Obama and Jill Biden heard of the clinic, they invited Flores and other representatives of the clinic to visit the White House earlier this year.

The hope, Flores said, is that they can develop a roadmap that other states can use to help their own veterans.

While William & Mary provides the legal expertise, the CPSD provides the medical diagnostics. The majority of cases are patients suffering from PTSD, although there also are cases of traumatic brain injury and moral injury.

Most of the patients are men. Some are homeless or destitute, Flores said. Sometimes the clinic helps the patients receive more monetary benefits.

“So we have had individuals who have been homeless and who now can actually get an apartment with these additional finances,” Flores said. “Sometimes it results in just added benefits at the VA and they can get the individual therapy or the group therapy for the PTSD treatment that they needed for so long.

“Other cases that we’ve had, the veteran has been trying to go back to school and they’re having problems in school, too, because they can’t concentrate and they’re worried about where the chair is and, you know, ‘that person looks kind of suspicious,’ and so we’ve been able to use our evaluations to help get veterans accommodations in classrooms that will help them do better in school.”

Among the numerous benefits that the veterans can accrue, one of the most important is therapy.

“Many of these guys have never actually sat down with somebody and talked about what’s happened,” Flores said. “And so getting them to actually continue to get services, whether it be with the VA or not, is a success for us.”

Unfortunately, therapy still has a stigma attached to it for PTSD and TBI patients, and Flores says it could be even harder for those suffering from moral injury to seek help.

“I can predict that it will be even harder for them to seek services over an issue for which they by definition feel ashamed of,” she said. “This is where we are seeing church and other faith organizations becoming more involved in working with service members — it seems to ‘fit’ more in people's conceptualizations for who would best address these issues.”

Bringing these issues to the forefront can only help  veterans, both those contemplating suicide because they feel they have no other options, and those who are haunted by anxiety or guilt and are too ashamed to seek therapy.

“I am heartened by the increased dialogue in our society about the issue of moral injury and the efforts to address it,” Flores said. “We owe it to the men and women we send out to fight our wars to help them rebuild their lives once they return.

“Not only do we need to help them become educated and obtain jobs, but we need to ensure that they can return to live as fulfilling a life as possible with their loved ones and themselves. We cannot do that by ignoring or minimizing the psychological and existential wounds they sustain in service to our country.”


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