When Richard Robinson sought treatment for post-traumatic stress in 2007, he was told at first that he couldn't have PTSD because he was never in a combat unit. Robinson, an Army veteran who served in the aftermath of the Gulf War, had been a mechanic on a medical evacuation aircraft retrieving bodies many of them civilians.
Most of them were little children, 10 years of age or younger little kids who had stepped on landmines chasing after a ball or a puppy, said Robinson, now a 55-year-old father of three adult children.
"I picked up the pieces of what war left people in. You go out, pick up a maimed body, bring it back and talk about what a great mission that was. It stopped making sense.
In the end, after Robinson described his symptoms, the social worker did diagnose him with PTSD and he received treatment. But since then, the Veterans Administration and other organizations have begun to look seriously at new research on moral injury, a condition related to PTSD that helps explain stories like Robinsons.
Moral injury occurs when people witness or participate in something that goes against their personal values or moral code. It can happen to anyone, but its common in war especially modern war, in which civilian casualties are high and battle lines are blurry. Using deadly force to cause combatant or civilian deaths, seeing a comrade die in battle, following illegal or immoral orders or being unable to help someone who is injured can all inflict a moral wound, according to the Moral Injury Project at Syracuse University.
While PTSD is a fear-based response stemming from an experience of physical danger, moral injury involves guilt and shame, said Penny Phillips, a staff chaplain at the Palo Alto VA Hospice and Palliative Care Center, speaking at the Parliament of World Religions in Salt Lake City in October.
Such emotions can often keep veterans from returning to a church or faith community, Phillips said. Their experiences may also have challenged or changed their former beliefs. Churches are uniquely positioned to help vets heal from moral injury, but because they are often uninformed, their well-intentioned efforts to help can backfire and push veterans away, said Rita Nakashima Brock, director of the Soul Repair Center at Brite Divinity School in Fort Worth, Texas.
The thing thats so devastating about moral injury is that it is extremely isolating. Its an inner anguish that can lead to you feeling like youre not a good person and if anybody ever figures that out, theyre never going to love you again, Brock said. Its important for faith communities to get educated so they dont become more isolating.
Modern warfare
Moral injury and PTSD are processed in different parts of the brain, Brock said. PTSD involves fear and affects the limbic system, or emotional brain. Once the symptoms of PTSD are calmed, moral questions start to come up in the thinking brain, or prefrontal cortex, where moral reasoning takes place, she said.
Moral injury is not an official psychological or medical diagnosis, and research on the topic is still in its infancy. But the VA has published a backgrounder on the issue and the Navy is including it as part of a residential treatment program.
There is some overlap in symptoms between PTSD and moral injury, Phillips said, and a person can suffer from one or both. Both can involve anger, depression, anxiety or self-medication with drugs or alcohol. PTSD can also involve memory loss and flashbacks. Moral injury is unlikely to include such symptoms, but instead involves grief, regret, alienation or shame, she said. In extreme cases, veterans can be so haunted by the things they saw or did that they become suicidal.
Phillips doesnt use the term PTSD. She refers to PTS, or post-traumatic stress, leaving off the word disorder. Soldiers dont like that term, she said, because it makes it sound like they have a disease, when in reality, they are having a normal reaction to horrific events. Not having such a reaction would be more disordered, she said.
Moral injury is particularly common in modern warfare because civilian casualties are high and there are no distinct battle lines, said Donna Smith, a senior minister at the Center for Spiritual living in Anacortes, Washington, who also served 32 years in the military, including on the planning committee for the Iraq war.
Smith referenced a scene in American Sniper, a controversial 2015 film based on real-life events, in which a Navy seal shoots a little boy carrying a bomb. Its a common scenario in todays wars in the Middle East, she said.
That just doesnt resonate with American soldiers, having to shoot children who have grenades, whose parents have strapped some kind of an explosive device to them. Its one thing to be fighting the adults, but when they send their children in with explosives, thats even harder to deal with, she said.
Troops can enter a city thinking its friendly only to be engaged in a firefight, she said. They have the constant adrenaline push of never knowing whether the person walking toward them or driving up to a checkpoint is a friend or an enemy. Opposition fighters use women and children as human shields. Soldiers are left questioning the split-second decisions they make decisions that could have had negative moral repercussions either way, making moral injury practically unavoidable.
Civilian deaths have been high in the Iraq conflict. A conservative estimate is that 137,000 civilians died as a direct result of war in that country between October 2001 and April 2015, according to the Costs of War project at Brown University. By comparison, just 4,489 U.S. troops died in Iraq during the same time period. Civilian deaths have been steadily rising in Afghanistan in recent years, with 3,699 documented in 2014 alone.
A 2003 study of 3,761 troops who had just returned from Iraq found that 28 percent of Marines and 14 percent of Army soldiers said they were responsible for the death of a noncombatant. Large percentages (69 percent of soldiers and 83 percent of Marines) also reported seeing ill or injured women or children whom they were unable to help. Roughly half had handled human remains.
In addition to moral emotions such as shame, guilt and anger, symptoms of moral injury can include spiritual struggles and issues with forgiveness, especially self-forgiveness, Phillips said. They can also include renegotiating a relationship with a persons faith or faith community.
Robinson, who was raised Mormon, said his views on war and on God began to evolve as a result of his experiences in Iraq.
You start thinking about, who is this God that cares and love us? I don't see him on our side. I don't see him on their side. It's supposed to be this holy war and I don't see God anywhere out here," he said. "I got confused because I can't understand any religion that tries to justify war and killing.
He's found some peace in Buddhist teachings, though hes also still on the membership rolls of the Church of Jesus Christ of Latter-day Saints.
"I'm still trying to make heads or tails of all this stuff."
The role of faith communities
Returning veterans often dont want to return to their places of worship because theyre afraid of being told theyre no longer one of the group, Phillips said. Their fear is compounded by the fact that churches are often uninformed and ill-prepared to meet the needs of returning vets.
Some anti-war churches dont know how to reconcile their views with the fact that they have veterans in their midst. Ive actually had church leaders say to me, But were against war. How can we welcome our veterans? she said.
On the other extreme, some churches fawn over veterans, calling them heroes and placing them on a pedestal, Brock said.
"It's been very difficult for faith groups to really grasp the depth of what all this is about, Smith said.
Yet faith communities are also uniquely suited to help veterans heal from moral injury, Brock said. Religious institutions commit to people for their entire lives, they understand grief and penance and they know what it means to violate core moral values.
There are ways for handling it in faith communities that are beyond what I would call the therapeutic treatment model, she said.
Brock has two pieces of advice for church leaders. First, dont patronize veterans.
My experience is that vets are very allergic to a paternalistic attitude. They dont want people taking care of them, she said. They are people who have survived a lot and want to be respected for that.
Christians try to follow the biblical call to care for the least of these, but veterans are not the least of these," Brock said. Theyre not victims. Thats why moral injury is important theyre willing to try to take some responsibility for what they did, and I think thats a healthy thing.
The second piece of advice is to make room for anger, which is a normal part of both PTSD and moral injury.
Most churches are terrified of anger. They dont like conflict, so they will shame somebody who gets angry, she said. Underneath anger is often a whole lot of grief. If (church members) dont enable that anger to run itself out, you often never get to the grief, you just shame the person and they go away.
One of the most important ways to provide spiritual care for veterans with moral injuries is to simply be present for them, listening actively and nonjudgmentally and asking questions carefully and respectfully, Phillips said.
Questions like, What was it like over there? How many people did you kill, and how was that, and what did they look like? are inappropriate and wont engage veterans, Phillips said. She suggests questions like, Are there any experiences or memories related to your time in the service that still trouble you? Where was God in all of this for you? and Where are you going now with it?
Phillips said listeners need to be prepared for intense responses and know in advance what resources are available in their communities, from the VA to local food banks to mental health resources.
Robinson said the most helpful conversations for him were those that didnt try to judge or explain anything. His father, a church leader, simply validated him: All he said was, I couldnt have gone through what you went through, Robinson said.
Robinson also recalls a meeting in which a church leader spoke about why the innocent suffer. Im all ready to shoot down whatever he has to say, and all he says is, We don't know. And I'm like, I can accept that. You shouldn't try to rationalize why people hurt, why children are killed. We don't know," Robinson said.
Veterans dont need people to tell them its OK or fix their problems, Phillips said. They need someone to simply sit and listen, let them tell the story over and over again because the more they talk about it, the less power it has, and the more they can put it into perspective, she said.
Hope and healing
One of the greatest tools faith communities have to offer those struggling with moral injury is a deep understanding of grief and rituals for processing it, Brock said.
Smith does a ritual with returning veterans in which she has them write letters of forgiveness to themselves and anyone else they feel they need to. It was something she first did with her own daughter after she returned from serving in Iraq.
I say, this piece of paper, its not going to talk back to you. Its not going to say, thats not right. You know what youre feeling. You know what it is that you're holding inside. So write a forgiveness letter, Smith said.
After they write the letters, then we burn them so a) nobody finds them, and b) it's a form of releasing the words to the universe, so they never have that experience again. They get to see it just disappear.
She said workshops where veterans tell their stories can also be powerful. "It's really taking the time and taking the opportunity to honor these kids and find activities or rituals to help them move through whatever they need to move through, she said.
The Soul Repair Center is working to raise awareness among faith communities of what they can do to more effectively help veterans heal from moral injury. In October, the center held a national conference that brought together nearly 250 military chaplains, clergy, veterans, families and others to talk about the issue. It has also held 10 regional events over the last three years and offers sermons, study guides and other worship helps for churches and seminaries.
Smith said the most important thing is for religious communities to create spaces for veterans to tell their stories without judgment. They need to be honored because they did exactly what their country asked them to do. Feeling that kind of safe sanctuary in their spiritual home thats what needs to happen, she said.
Most of them were little children, 10 years of age or younger little kids who had stepped on landmines chasing after a ball or a puppy, said Robinson, now a 55-year-old father of three adult children.
"I picked up the pieces of what war left people in. You go out, pick up a maimed body, bring it back and talk about what a great mission that was. It stopped making sense.
In the end, after Robinson described his symptoms, the social worker did diagnose him with PTSD and he received treatment. But since then, the Veterans Administration and other organizations have begun to look seriously at new research on moral injury, a condition related to PTSD that helps explain stories like Robinsons.
Moral injury occurs when people witness or participate in something that goes against their personal values or moral code. It can happen to anyone, but its common in war especially modern war, in which civilian casualties are high and battle lines are blurry. Using deadly force to cause combatant or civilian deaths, seeing a comrade die in battle, following illegal or immoral orders or being unable to help someone who is injured can all inflict a moral wound, according to the Moral Injury Project at Syracuse University.
While PTSD is a fear-based response stemming from an experience of physical danger, moral injury involves guilt and shame, said Penny Phillips, a staff chaplain at the Palo Alto VA Hospice and Palliative Care Center, speaking at the Parliament of World Religions in Salt Lake City in October.
Such emotions can often keep veterans from returning to a church or faith community, Phillips said. Their experiences may also have challenged or changed their former beliefs. Churches are uniquely positioned to help vets heal from moral injury, but because they are often uninformed, their well-intentioned efforts to help can backfire and push veterans away, said Rita Nakashima Brock, director of the Soul Repair Center at Brite Divinity School in Fort Worth, Texas.
The thing thats so devastating about moral injury is that it is extremely isolating. Its an inner anguish that can lead to you feeling like youre not a good person and if anybody ever figures that out, theyre never going to love you again, Brock said. Its important for faith communities to get educated so they dont become more isolating.
Modern warfare
Moral injury and PTSD are processed in different parts of the brain, Brock said. PTSD involves fear and affects the limbic system, or emotional brain. Once the symptoms of PTSD are calmed, moral questions start to come up in the thinking brain, or prefrontal cortex, where moral reasoning takes place, she said.
Moral injury is not an official psychological or medical diagnosis, and research on the topic is still in its infancy. But the VA has published a backgrounder on the issue and the Navy is including it as part of a residential treatment program.
There is some overlap in symptoms between PTSD and moral injury, Phillips said, and a person can suffer from one or both. Both can involve anger, depression, anxiety or self-medication with drugs or alcohol. PTSD can also involve memory loss and flashbacks. Moral injury is unlikely to include such symptoms, but instead involves grief, regret, alienation or shame, she said. In extreme cases, veterans can be so haunted by the things they saw or did that they become suicidal.
Phillips doesnt use the term PTSD. She refers to PTS, or post-traumatic stress, leaving off the word disorder. Soldiers dont like that term, she said, because it makes it sound like they have a disease, when in reality, they are having a normal reaction to horrific events. Not having such a reaction would be more disordered, she said.
Moral injury is particularly common in modern warfare because civilian casualties are high and there are no distinct battle lines, said Donna Smith, a senior minister at the Center for Spiritual living in Anacortes, Washington, who also served 32 years in the military, including on the planning committee for the Iraq war.
Smith referenced a scene in American Sniper, a controversial 2015 film based on real-life events, in which a Navy seal shoots a little boy carrying a bomb. Its a common scenario in todays wars in the Middle East, she said.
That just doesnt resonate with American soldiers, having to shoot children who have grenades, whose parents have strapped some kind of an explosive device to them. Its one thing to be fighting the adults, but when they send their children in with explosives, thats even harder to deal with, she said.
Troops can enter a city thinking its friendly only to be engaged in a firefight, she said. They have the constant adrenaline push of never knowing whether the person walking toward them or driving up to a checkpoint is a friend or an enemy. Opposition fighters use women and children as human shields. Soldiers are left questioning the split-second decisions they make decisions that could have had negative moral repercussions either way, making moral injury practically unavoidable.
Civilian deaths have been high in the Iraq conflict. A conservative estimate is that 137,000 civilians died as a direct result of war in that country between October 2001 and April 2015, according to the Costs of War project at Brown University. By comparison, just 4,489 U.S. troops died in Iraq during the same time period. Civilian deaths have been steadily rising in Afghanistan in recent years, with 3,699 documented in 2014 alone.
A 2003 study of 3,761 troops who had just returned from Iraq found that 28 percent of Marines and 14 percent of Army soldiers said they were responsible for the death of a noncombatant. Large percentages (69 percent of soldiers and 83 percent of Marines) also reported seeing ill or injured women or children whom they were unable to help. Roughly half had handled human remains.
In addition to moral emotions such as shame, guilt and anger, symptoms of moral injury can include spiritual struggles and issues with forgiveness, especially self-forgiveness, Phillips said. They can also include renegotiating a relationship with a persons faith or faith community.
Robinson, who was raised Mormon, said his views on war and on God began to evolve as a result of his experiences in Iraq.
You start thinking about, who is this God that cares and love us? I don't see him on our side. I don't see him on their side. It's supposed to be this holy war and I don't see God anywhere out here," he said. "I got confused because I can't understand any religion that tries to justify war and killing.
He's found some peace in Buddhist teachings, though hes also still on the membership rolls of the Church of Jesus Christ of Latter-day Saints.
"I'm still trying to make heads or tails of all this stuff."
The role of faith communities
Returning veterans often dont want to return to their places of worship because theyre afraid of being told theyre no longer one of the group, Phillips said. Their fear is compounded by the fact that churches are often uninformed and ill-prepared to meet the needs of returning vets.
Some anti-war churches dont know how to reconcile their views with the fact that they have veterans in their midst. Ive actually had church leaders say to me, But were against war. How can we welcome our veterans? she said.
On the other extreme, some churches fawn over veterans, calling them heroes and placing them on a pedestal, Brock said.
"It's been very difficult for faith groups to really grasp the depth of what all this is about, Smith said.
Yet faith communities are also uniquely suited to help veterans heal from moral injury, Brock said. Religious institutions commit to people for their entire lives, they understand grief and penance and they know what it means to violate core moral values.
There are ways for handling it in faith communities that are beyond what I would call the therapeutic treatment model, she said.
Brock has two pieces of advice for church leaders. First, dont patronize veterans.
My experience is that vets are very allergic to a paternalistic attitude. They dont want people taking care of them, she said. They are people who have survived a lot and want to be respected for that.
Christians try to follow the biblical call to care for the least of these, but veterans are not the least of these," Brock said. Theyre not victims. Thats why moral injury is important theyre willing to try to take some responsibility for what they did, and I think thats a healthy thing.
The second piece of advice is to make room for anger, which is a normal part of both PTSD and moral injury.
Most churches are terrified of anger. They dont like conflict, so they will shame somebody who gets angry, she said. Underneath anger is often a whole lot of grief. If (church members) dont enable that anger to run itself out, you often never get to the grief, you just shame the person and they go away.
One of the most important ways to provide spiritual care for veterans with moral injuries is to simply be present for them, listening actively and nonjudgmentally and asking questions carefully and respectfully, Phillips said.
Questions like, What was it like over there? How many people did you kill, and how was that, and what did they look like? are inappropriate and wont engage veterans, Phillips said. She suggests questions like, Are there any experiences or memories related to your time in the service that still trouble you? Where was God in all of this for you? and Where are you going now with it?
Phillips said listeners need to be prepared for intense responses and know in advance what resources are available in their communities, from the VA to local food banks to mental health resources.
Robinson said the most helpful conversations for him were those that didnt try to judge or explain anything. His father, a church leader, simply validated him: All he said was, I couldnt have gone through what you went through, Robinson said.
Robinson also recalls a meeting in which a church leader spoke about why the innocent suffer. Im all ready to shoot down whatever he has to say, and all he says is, We don't know. And I'm like, I can accept that. You shouldn't try to rationalize why people hurt, why children are killed. We don't know," Robinson said.
Veterans dont need people to tell them its OK or fix their problems, Phillips said. They need someone to simply sit and listen, let them tell the story over and over again because the more they talk about it, the less power it has, and the more they can put it into perspective, she said.
Hope and healing
One of the greatest tools faith communities have to offer those struggling with moral injury is a deep understanding of grief and rituals for processing it, Brock said.
Smith does a ritual with returning veterans in which she has them write letters of forgiveness to themselves and anyone else they feel they need to. It was something she first did with her own daughter after she returned from serving in Iraq.
I say, this piece of paper, its not going to talk back to you. Its not going to say, thats not right. You know what youre feeling. You know what it is that you're holding inside. So write a forgiveness letter, Smith said.
After they write the letters, then we burn them so a) nobody finds them, and b) it's a form of releasing the words to the universe, so they never have that experience again. They get to see it just disappear.
She said workshops where veterans tell their stories can also be powerful. "It's really taking the time and taking the opportunity to honor these kids and find activities or rituals to help them move through whatever they need to move through, she said.
The Soul Repair Center is working to raise awareness among faith communities of what they can do to more effectively help veterans heal from moral injury. In October, the center held a national conference that brought together nearly 250 military chaplains, clergy, veterans, families and others to talk about the issue. It has also held 10 regional events over the last three years and offers sermons, study guides and other worship helps for churches and seminaries.
Smith said the most important thing is for religious communities to create spaces for veterans to tell their stories without judgment. They need to be honored because they did exactly what their country asked them to do. Feeling that kind of safe sanctuary in their spiritual home thats what needs to happen, she said.