Military Service and Moral Injury

by Mental Health

Dulce et decorum est, pro patria mori – it is sweet and right to die for your country. The first section, the Latin for “it is sweet and right” served as title for one of the best known poems from the First World War by Wilfred Owen. Posed as a question, Owen’s prose describes military service in terms similar to Smith’s (2010) description of war as “mangled bodies and shattered minds.” What is remarkable about both instances, nearly 100 years apart, is the absence of any glorious praise. There are no parades, no football game announcements, no carefully tailored Hollywood grandiosity. Instead there is brutality and death.

The far-reaching consequences of engagement in war is rarely explored in the news beyond flashy pronouncements of the latest enemy leader killed. Of the mangled bodies the public is rarely shown. It is to shattered minds that we turn. Newsweek, in 2012, posted an article concerning veterans. In it:

“Self-harm is now the leading cause of death for members of the Army, which has seen its suicide rate double since 2004, peaking this past summer with 38 in July alone. But the risk to discharged veterans may be even greater. Every month nearly 1,000 of them attempt to take their own lives. That’s more than three attempts every 90 minutes, at least one of them successful.” (Newsweek)

The numbers above come from 2004 and, from the latest in Military Times, this trend has continued. “A new study of suicide attempts by Army soldiers finds those most at risk are troops who never deployed as well as those in their second month of military service.” This data is a confirmation of what Defense Department has known for five years, that half those who attempt suicide are young, new to military service and have never deployed. However, those who do deploy are at highest risk in the first six months and the first five months after returning.

The utilization of Post-traumatic Stress Disorder (PTSD) for explanation only goes so far. Further, these numbers hide the broader stress and mental health symptoms being experienced by the families of those in service. PTSD is based on a fear-model, where, according to the DSM-V, the person must have “exposure to actual or threatened death, sexual injury or sexual violence.” While there is an allowance for secondary trauma, it is still based on fear of an actual or threatened event and data is sparse for just how this mechanism works for the creation of enduring symptoms (Nash & Litz, 2013).

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While the latter is open to further empirical studies, a deeper question is raised as to whether fear conditioning is the only criteria for making an event traumatic. Before going into the potential answer of ‘moral injury,’ we should explore the nature of American military service.

The American Framing of Military Service

“The American military has been called “the world’s best killing machine,” and yet the word killing is the last thing you’ll hear the military discuss. The word doesn’t appear in training manuals, or surveys of soldiers returning from combat, and the effects of killing aren’t something the military screens for when service people come home. It’s strictly a private word, something hissed about in bars and between bunk beds.” (Newsweek)

Behind the medals, the pomp and circumstance, ribbons pinned to shirts and flags waving from front porches, there is the reality of what a military does that is rarely voiced beyond opaque verbiage. Whether a service-member is tasked with firing a weapon, all are initially trained to do so. Yet, attempt to replace “thank you for your service” with “thank you for your willingness to kill.” Finding it difficult? Now ask why that is. The answer should not be simple and it should not be kind. As a nation we are asking people to deliberately engage in an act that we send others to jail or a mental ward for. Yes, reasons matter and this is not a comparison of military service to murder. What this is, is a refusal to use those reasons as a means to hide the request and demand to kill.

Those reasons are informed by how the world is framed, the means by which action and consequence are linked. With cries of “that isn’t right!” often following tragedy or pain and military engagement being referred to in clear demarcations of “Us vs Enemy,” “good and evil,” there is little room for the gray areas of dealing with reality. Contrary to Hollywood depictions, which are about as close to war that most Americans will ever get, the enemy is not as easily identified as if picking lights and darks for laundry. However, what this simplistic frame, called the “just-world” belief, offers, is a sense of control.

“The alternative, acknowledging that bad things can happen to anyone, or be done by anyone, is too much to bear. Researchers have found that belief in the just-world myth is especially strong in the United States. Indeed, many of the ideals of American culture — that hard work will lead to success, that poverty is the result of laziness or poor moral fiber, and that success is due to merit, rather than luck or unfair advantage — are rooted firmly in just-world beliefs.” (Vox)

Couched in this frame, the training for and active participation in, killing, is pushed to the side in favor of “fantasies of valor and righteousness” (Smith, 2010). Beyond making any nuanced discussion of how and why a nation goes to war nearly impossible, worse is done to those who are still being tasked with killing in its name.

Moral Injury

When discussing moral injury, it is important to note immediately that this is not about judgment of those in service. Rather, the morality in question is precisely of those in service, it is the recognition that their humanity is something deeper and deserving of more appreciation than merely being boxed into a single act. This is, ultimately, about the better angels of our nature.

Moral injury started with psychologist Jonathan Shay as part of his work with Vietnam veterans. “Shay coined the term ‘moral injury’ as a way to describe the traumatic feelings of betrayal and shame that many of his Vietnam veteran patients felt when the military violated the moral construct it had instilled in them” (Vox).

Needing to broaden the definition for further study,

“…Litz et al. (2009) defined moral injury in war veterans as the enduring consequences of perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations. Central to the concept of moral injury is an event that is not only inconsistent with previous moral expectations, but which has the power to negate them. Moral injury is not merely a state of cognitive dissonance, but a state of loss of trust in previously deeply held beliefs about one’s own or others’ ability to keep our shared moral covenant.” (Nash & Litz, 2013)

More than killing, moral injury can come out of a sense of betrayal as well, when a person in authority violates a moral principle they were supposed to have kept safe. There is a deep sense of trust required for military service, a near abdication of one’s own reason, a faith, as it will, in the power and security of the structure the person has chosen to beholden themselves.

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“Moral beliefs and values shared across social boundaries, as a moral covenant, not only make social interactions predictable and meaningful, they lay a foundation for enduring relationships of trust and safety” (Nash  Litz, 2013). These covenants are often implicit, hitting us forcefully often only when violated, as when a friend or family member has harmed or acted in a form of betrayal. For those in the military, tasked already with committing acts that in their civilian world are shunned, this trust and safety is paramount. Violation “is marked by feelings of shame, guilt, and self-blame. In its more severe forms, it is often accompanied by self-destructive behaviors and can lead to suicide” (Vox).

The notion of moral injury would have little utility were it not capable of showing itself to be quantifiably different than the fear-model at the core of PTSD. Utilizing the questionnaire Moral Injury Events Scale (MIES), “…scores on the MIES in 533 infantry Marines who recently returned from combat deployments to Iraq or Afghanistan correlated with PTSD symptoms and other markers of psychological distress and dysfunction, but they did not correlate significantly with scores on self-report measures of exposure to life-threatening combat events, confirming that potentially morally injurious events can be discriminated from events that threaten life and safety.” (Nash & Litz, 2013)

While there is certainly more research to be done, the significance of moral injury as an additional means of understanding the trauma of service-members cannot be overstated. In asking professionals what characterized moral injury, themes emerged:

“…social and behavioral problems, trust issues, spiritual and existential issues, psychological problems, and self-deprecation. Reported social and behavioral problems possibly associated with moral injury ranged from social withdrawal and alienation to aggression, misconduct, and sociopathy. Possible spiritual and existential symptoms included loss of religious faith, loss of trust in morality, loss of meaning, and fatalism. Possible psychological symptoms included depression, anxiety, and anger, while the characteristic self-deprecating emotions and cognitions thought to be associated with moral injury included shame, guilt, selfloathing, and feeling damaged.” (Nash & Litz, 2013)

An Invitation to Reflect

In case there was a thought that the numbers from the Newsweek article are too old, consider this from the recent Military Times article:

“For the past three years, suicides among all active duty personnel have remained steady, down to 266 in 2015 from a peak of 321 in 2012. Still, the suicide rate across the armed forces is nearly double it was before Sept. 11, 2001.”

Litz et al.’s (2013) model of moral injury focuses on “shame, guilt, and self-destructive impulses, and their perpetuation because of an inability to forgive oneself for failing to live up to one’s own moral expectations.” The separation from one’s internal sense of right and wrong, combined with a dissociation from the rest of society that military service incurs, breeds a deep feeling of isolation. As also occurs in PTSD, there is a belief that the responsibility for one’s actions lay solely on themselves. The moral injury frame allows us to broaden the discussion of the effects of war and place responsibility more squarely on society as a whole. Hopefully, from this community-base there can be a reduction in self-harm.

In a review of Killing From the Inside Out, Lt. Col. Douglas A. Pryer says: “Perhaps Meagher is right. Perhaps our nation should choose its wars much more carefully. And perhaps, to achieve the best possible outcomes from a truly necessary conflict, we American soldiers must understand ourselves not as self-exalting holy warriors but more fully and rationally, better accounting for who we are, what we do, and what we do to ourselves when we wage war.”

That understanding should not simply be the purview of American soldiers, but of the society that has tasked them with doing the, usually, unthinkable. Their moral injury is most assuredly a burden we all should bear.

© David Teachout


Dokoupil, T., & Snyder, A. (2012). MORAL INJURY. Newsweek, 160(24), 40-44.

Kime, Patrick. Soldiers at highest risk for suicide attempts in first year of service. Military Times.

Nash, W. P., & Litz, B. T. (2013). Moral Injury: A Mechanism for War-Related Psychological Trauma in Military Family Members. Clinical Child & Family Psychology Review, 16(4), 365-375. doi:10.1007/s10567-013-0146-y

Smith, David Livingstone (2010-04-01). The Most Dangerous Animal: Human Nature and the Origins of War (p. 7). Macmillan. Kindle Edition.

Taub, Amanda. (2015, May 25). Moral injury — the quiet epidemic of soldiers haunted by what they did during wartime. Vox.

Further Reading:

Currier, J. M., Holland, J. M., Drescher, K., & Foy, D. (2015). Initial Psychometric Evaluation of the Moral Injury Questionnaire-Military Version. Clinical Psychology & Psychotherapy, 22(1), 54-63. doi:10.1002/cpp.1866

Overland, G. (2014). Moral Obstacles: An Alternative to the Doctrine of Double Effect. Ethics, 124(3), 481-506.

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