Why “moral injury,” like “PTSD” is a term that applies to far more than our soldiers, and why that’s important to all of us

What Have We Done coverI recently finished reading the book What Have We Done: The Moral Injury of Our Longest Wars, by Pulitzer-prize-winning war journalist David Wood (Little, Brown, 2016). When my husband brought it home from the library my interest was piqued because I hoped it might give me insight into why the abusive situations I’ve known about involved what seemed like a disproportionately high percentage of abusers who were military veterans.

Well, that particular insight didn’t happen. What happened instead was an understanding of the term “moral injury,” which I hadn’t heard before, as well as a growing awareness and understanding of the fact that what David Wood chronicles clinicians as having observed and labelled in ground troops has also appeared in the lives of people I know personally who suffered abuse and betrayal at the hands of people who should have cared for them.

A new descriptive term

soldier covering his faceHere’s the definition for “moral injury” the doctors arrived at after years of recognizing problems that couldn’t truly be categorized as PTSD:  “the lasting psychological biological, spiritual, and social impact of perpetuating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations” (p 250, italics mine).

David Wood gives war-time examples such as a soldier shooting a child or a soldier watching a buddy get blown up that he thinks he could have or should have saved. Experiences like these don’t simply cause PTSD; in fact, he argues, the effect goes far deeper. To draw the contrast with PTSD, p 18 tells us, “PTSD has little to do with sin. It is a psychological wound caused by something done to you. Someone with PTSD is a victim. A moral injury is a self-accusation, promoted by something you did or something you failed to do, as well as something done to you.”

And now I want to repeat that definition, but adding a bit to it in order to apply it to the realm of domestic and sexual abuse:  “A moral injury is a self-accusation, promoted by something you believe you did or something you believe you failed to do. . . .” Especially when one is a child or one has been deeply indoctrinated, the moral injury is every bit as profound, and a person will have to grapple with a perceived wrong that may not be a genuine wrong.

Say for example, that a husband has broken the dog’s legs because, he tells his deeply-indoctrinated wife, “you always want to keep your precious floors so clean, and he was walking in here with dirty feet. You know how you get when your floors get dirty.” She is tangled in confusion, believes she is at fault, and takes on herself the blame, at least some of it, for her crippled dog. This is beyond PTSD. It is a moral injury.

Or say after raping his young daughter, a father shows her the word “whore” in the dictionary so she can receive the full weight of the meaning of the word when he snarls it to her every time he rapes her thereafter. As an adult, PTSD describes the fear she feels when she hears footsteps coming down the hall. But believing she is a whore goes far deeper, into the deepest places of her identity. It is a moral injury.girl covering her face

The examples can continue almost endlessly as abusers seem to have an endless array of weapons of emotional abuse to make their victims feel responsible for their own crimes. And abusers have also forced their victims to participate in actual crimes, even brutal ones, in order to slash a moral injury on the soul of the victim.

To increase and even cement the most gangrenous soul wound possible, the wicked abuser will claim to be committing the heinous cruelty in the name of the true God of heaven.

And the enablers—they get a full chapter each in both Unholy Charade and Tear Down This Wall of Silence—they execute moral injuries of their own. When I’ve discussed this concept with people in the past, I’ve talked about the blaming and shaming, betrayal, false guilt, identity issues, grief, and more, but David Wood’s book wraps them all up into this all-encompassing carefully-chosen term.

The term, in fact, was developed by Jonathan Shay, a clinician who worked with Vietnam combat veterans and saw issues that he believed couldn’t be classified under PTSD. He is the one who coined the term “moral injury,” saying that it is “the violation of the collective and deeply personal sense of ‘what’s right’” (p 91).

And isn’t that the case with many victims of abuse, especially childhood sexual abuse? They carry a part of themselves who perhaps on some level “participated” in the some aspect of the shameful, degrading, unspeakable, humiliating, and criminal activities, and another part that condemns themselves for participating.woman curled in a ball

The injury of moral violation

Calling it an injury rather than a disorder, Wood observes, is important because that indicates the condition can be healed. Though of course this wasn’t a Christian book and the clinicians continue to discuss pros and cons of various methods of healing, most of them agree that as much as possible replacing lies with truth is a huge component to bringing a morally wounded person back to wholeness. As was noted on p 129, “‘[M]ost wounds, people get over them. But your chances of getting over it are far better if you acknowledge that you’ve been wounded’ and are given appropriate treatment.”

With chapter titles like “It’s Wrong but You Have No Choice,” “Grief is a Combat Injury,” “Vulnerable,” and “Betrayal,” the book gave one parallel after another to the world of sexual and domestic abuse. Some abuse survivors who have grown up in homes that were like war zones, who never knew when their enemy, the abuser, might strike, could most likely even relate to the concept of their wounds being “combat injuries.”

Another parallel that reminded me of the Enablers came from a soldier who told Wood (p 203), “When things go down . . . the people in charge aren’t there. The people in charge who are supposed to make the decisions are hiding behind walls and behind bulletproof glass because they have a career. They’re not there to get shot at. They’re not there to risk their lives to help us. They’re there to further their career, get a medal, and move on to the next command. Take credit for our good deeds and disown our bad deeds.”

This, of course, reminded me of the leaders in churches and Christian schools and other Christian institutions who will parade their model member/student in front of an audience for all to see and admire, until that student says he or she has been abused . . . when the leaders are not to be found, except, all too often, in support of the abuser. After all, no matter what they say their purpose is, it’s when their personal reputation and the reputation of their institution is threatened that their true character is shown. Are they there to serve the cause of Christ? All too often, “they’re there to further their career.”

I would love to talk about how the shameful way the military has historically treated moral injuries, because I found that information fascinating, but I want to end by exploring one of the conundrums of treatment.

Even after the VA started trying to make changes from the practically-prehistoric-in-every-way treatment style they’d been following, studies found that CPT (cognitive processing therapy) and PE (prolonged exposure therapy), though they’ve been the preferred method of treatment for soldiers since 2008, weren’t as effective as they were for civilians. And why not?

Perhaps, according to a paper published in the Journal of the American Medical Association (JAMA) in 2015, “because war trauma is fundamentally unlike civilian trauma. Among those differences, they noted, were ‘the extended, repeated and intense nature of deployment trauma, and the fact that service members are exposed not only to life threats but to traumatic losses and morally compromising experiences that may require different treatment approaches’” (p 257, italics mine).

soldier compassionI italicized those words and phrases, because I thought about them in context of what the JAMA authors called “civilian trauma.” From what I could tell, they thought of civilian trauma as a discrete event. A car wreck, for instance. Or maybe stranger rape, as horrible as that is. There is a definite beginning point and a definite ending point.

But some “civilian” traumas, it has to be acknowledged, are far more similar to these military moral injuries. Some of them have been extended, repeated, and intense. Some of them  have involved traumatic losses. Many of them have involved morally compromising experiences. Some have been full of such utterly degrading and humiliating and horrific wickedness that the survivor of the trauma could not utter the words to express it even if she could find them.

And make no mistake, the survivor of a moral injury such as this can be someone who sits down the row from you at church or serves you your espresso at the coffee shop. She can be teaching music to your daughter or decorating your cake at the bakery. You may not notice it in casual interaction, but the moral injuries are extensive and sustained.

And because they’re injuries, they need to be cleaned out like wounds, sometimes deeply infected ones. This is where time, love, patience, and the willingness to listen come in, from a wise counselor, and even from caring friends. In fact, the last chapter of Wood’s book is called “Listen.” He calls on all Americans to do this for the veterans around them, to be willing to be that kind of friend.

woman with compassion 2The greatest love, I always tell my friends, is to be found in Jesus Christ, who poured out His love for us, not only on the cross, but also from His throne, into the lives of those who are willing to trust Him. But here we are, His hands and feet.

“That wickedness? That is not who God really is. Let me show you who He is. He is here, and He loves you. You are precious to Him.”

What better way to pour out the love that He pours into us than to offer time, love, patience, and willingness to listen to the deepest and darkest of moral injuries?

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