Care for the Sorrowing Soul: Healing Moral Injuries from Military Service and Implications for the Rest of Us by Duane Larson and Jeff Zust

 

[1] Our longest military conflict in U.S. history is still underway. Since 9-11 more than 4 million new veterans join the ranks of millions more who have preceded them. Veterans, families and professionals increasingly recognize that some veterans return with a variety of stress-related difficulties, including symptoms of depression, insomnia, withdrawal, isolation, chronic pain, marital strife or substance abuse.  Unexpected sleep disorders, sense of regret, sadness, loss of purpose and direction become confusing for the veteran, their family, and friends. Some hurting veterans hesitate to share information, and through a sense of shame or guilt, hold these memories deeply hidden.  Veterans silently and secretly carry this unexplained, unremitting, increasing pain and suffering.

[2] We now understand that a significant amount of this pain may be the result of moral injury. Many professionals (primary care physicians, psychiatrists, other mental health professionals, clergy, etc.) have never heard of moral injury and do not recognize or identify this “injury to the conscience and the soul.” Exploring his or her symptoms with the veteran before prematurely jumping to diagnostic categories may help uncover moral injury. Symptoms of moral injury overlap with post-traumatic stress disorder, which complicates an accurate assessment. In addition, moral injury symptoms can be missed by caregivers who are unaware of previous military history. Thus, the caregiver and the individual are disadvantaged if the fact of previous military experience is missed. Routinely asking a question like, “Have you or any of your family ever served in the military?” could open the door to a life-saving, healing process, even among veterans who never directly experienced combat. We know Vietnam War veterans continue to struggle with painful emotional experiences even after many years yet have never been able to disclose this pain to anyone.

[3] Along with other conditions not visible or easily identified, moral injury is considered one of the four hidden wounds of war: moral injury, post-traumatic stress, traumatic brain injury and military sexual trauma. Besides this “invisibility” factor, there are other reasons moral injury goes undiscovered:

(1) Moral injury is not a medical or psychiatric diagnosis and is not listed in the standard medical and psychiatric diagnostic manuals (Diagnostic and Statistical Manual of Mental Disorders; International Classification of Diseases, etc.).

(2) As noted above, some overlapping symptoms are found in both moral injury and post-traumatic stress disorder[PTSD] (anxiety, insomnia, depression, anger, nightmares, self-medication, etc.). Many clinicians are unfamiliar with moral injury and symptoms are mistakenly attributed to PTSD.

 (3) Symptoms related uniquely to moral injury (shame, regret, sorrow, grief, alienation, etc.) are typically not in the lexicon of many clinicians and are never explored. Indeed, if the clinician is personally uncomfortable inquiring about or dealing with such symptoms, they may not be adequately explored.

Taking a history to explore such “non-clinical” symptoms involves careful listening, sensitivity, patience and time. Taking time to clearly explore moral injury grows out of the professional commitment to the individual (and family) grounded in the ethical foundation of the clinician.

[4] Moral injury falls between the physical/emotional and spiritual aspects in our personhood. It can be considered a “soul injury” and an inner conflict. Many recognize the assessment and treatment are best done as a team, with clinical professionals and clergy professionals working together. Team members will need to collaborate addressing moral injury and each team member must understand and recognize the unique skills they bring to the healing process.

[5] The authors dedicate Care for the Sorrowing Soul “to those in military service whose moral goodness was wounded in combat and those who accompany the morally injured through their sorrowing toward emotional and spiritual healing.” While the book is written with the veteran in mind, moral injury is also a significant factor in our general population. For example, moral injury is experienced by first responders, caregivers, fatal accident survivors, sexual assault victims, as well as those who sense they have failed others in some way.

[6] This is not just another book on moral injury. Authors Duane Larson and Jeff Zust provide a major work of significant depth and breadth. They offer: (1) a comprehensive and extensively documented source of material highlighting the historical context of this often unrecognized and misunderstood dynamic; (2) current understandings of human growth and development, both individual and group, that impact development of moral injury; (3) principles to assist the reader in understanding the origins of the injury; (4) an understanding of the complexity of the suffering and costs of unresolved pain which robs individuals and families of meaningful and purpose-filled lives; and (5) a conceptual framework to understand a holistic and team approach to healing.

[7] While the book focuses on those who served in the military, it does not minimize the civilian groups mentioned above. We have growing recognition that issues arise not only for the post 9-11 veterans but also for the now maturing groups of veterans from World War II, Korea and the Vietnam era. Some veterans who moved smoothly out of active duty decades ago into meaningful and productive professional careers are now retiring. They sometimes find, with introspection and reflection, memories from their long-ago military experience mysteriously surface with resulting discomfort and potential personal anguish. Often children of a deceased veteran say, “He just never talked about these things.”  Ask the chaplain of a hospice program caring for veterans, how many times is it said: “Chaplain, I need to get something off my chest….” These memories and issues build, often resulting in tensions and confusion about reemerging memories resulting in withdrawal and isolation from family and friends. These emotions become counter-productive to what otherwise should be a time of life filled with family warmth and cohesion.

[8] Providers also may hear from puzzled, uncertain family members who struggle to relate and support a recently returned veteran family member. Loved ones make comments like: “I just don’t understand. She was such a happy, positive person, proud of her uniform… and now that she is back, she just is not the same; she has changed so much……I’m confused, I don’t know how to understand this change and I feel helpless….” Providers can use these uncertainties to continue the conversations since in listening and sharing there is the opportunity to move forward together in a supportive, caring and safe exploration process.

[9] Estimates show that 20+ veterans die by suicide each day. Unresolved, unhealed moral injury, with overwhelming shame and guilt, can be factors in this tragedy. Since 70% of those veterans dying by suicide have not recently sought help from the VA, these veterans are in our communities and require help from our community resources. Developing and organizing resources takes creativity and focus that can be life-saving.

[10] For the physician, clergy or therapist who takes the time to venture into moral injury, this book emphasizes that the assessment and exploration with the individual can be a slow, uncertain, non-linear process. There will be “starts and stops” as one moves through layers of memories and potentially overwhelming feelings. Veterans and helpers correct and revisit the perceptions that begin to flow. Issues of self-esteem, self-image and personhood may erupt unpredictably. Understandably, some physicians will feel they do not have adequate time, experience or skill to explore these issues and thus “avoid” any inquiry that might lead to opening up this painful reality. Therefore, a team process could be helpful, even necessary.

[11] Care for the Sorrowing Soul provides the reader with valuable insight into the complexities of moral injury; the idiosyncratic nature of the injury; the development of value systems and personal growth; and the life-long impact and change in identity that occurs during the process of “becoming a soldier” in basic training.

[12] The book may be divided into several major sections.  In Chapter 1 “Introduction” through Chapter 4 “Sources of the Self” the reader is guided into the complexity of who we are as moral beings. This includes the origins and elements of moral perspective in our personal and communal worlds. It recognizes just how personally unique is our individual growth and development. As the Bible asserts: “We are wonderfully made.” Far from static, humans are continually being formed by internal and external interactive processes that shift and reemerge. Identity and character respond to that which is both outside and inside conscious human experience. “Internal development” is often not taken up in the moral injury literature which tends to focus only on symptoms and interventions. Larson and Zust consider the human depths that influence and are influenced by moral injury.

[13] Starting with Chapters 5 and 6 “The Development of Military Character”; “The Role of Moral Senses in Directing and Judging Military Character” the reader follows how military basic training moves recruits from civilian to soldier. The significance of this transformation is often unappreciated by family, friends and professionals (physician, clergy, therapist, etc.) who have never been in the military. To understand the veteran, one must understand the life-changing impact of military basic training. Recruit training forever changes the individual (as it is said: “Once a Marine, always a Marine!”). It creates a mind-set that secures for the soldier an assurance that, when together with the others in the military, especially one’s own unit, certain values can be expected and relied upon. Combat requires and tests this training at a depth seldom understood by those who have never experienced combat. Chapters 5 and 6 expand on the intensity of the journey.

[14] Chapter 7 “Spiritual Dimensions for Mitigating and Healing Soul Suffering”, Chapter 8 “God’s Solidarity with the Morally Injured”, and Chapter 9 “Expressing and Healing Moral Injury” invite the reader to explore a personal dilemma: now that I am gaining a sense of the implications of all of this, what is my role and response to be? Healing is a long term process and done in community, and rarely is the community limited to just two people. If the reader is short on time, at least read the final Chapter 9: “Expressing and Healing Moral Injury” to open a window to the “why and how” of moral injury.

[15] Responsibility for our veterans coming home (not just “coming back”) lies not only with our hard working but chronically under-resourced Veterans Administration (VA). It lies also with us. Veterans coming home are integral to and the responsibility of our communities. The VA is a critically important resource and part of our larger community. Importantly, faith communities of all expressions are uniquely positioned to be involved, if they will. This book gives community groups a way to walk the journey with the veteran and family. Through this sometimes life-long healing process, the veteran can find new purpose, a new sense of understanding, and the personal acceptance that allows meaningful relationships.

[16] Care for the Sorrowing Soul provides a valuable addition to the discussion of moral injury. Some observations and suggestions about the book’s format are in order. Having the footnotes on each page was very helpful. However, there is no index, so the reader should make notes with listed pages to later find points considered personally significant. Acronyms and abbreviations are used throughout. Making a list of these will help those unfamiliar with some terminology move through the text more efficiently.

[17] Finally, in putting the book down after exploring the concepts the reader faces the question: what are my role-responsibilities to address moral injury? Where in our communities will we generate the compassion, commitment, resources and energy to be available to those who are carrying the burden of moral injury? Veterans are integral to our communities. How do we find those who are hurting? What can our congregations do? Studying this book together may be a good first step in that process!

 

Erv Janssen, M.D. is a retired psychiatrist, U.S. Navy.

 


Articles published in the journal reflect the perspectives and thoughts of their authors and not necessarily the theological, ethical, or social stances of the Evangelical Lutheran Church in America.​


© July/August 2018
​Journal of Lutheran Ethics
Volume 18, Issue 4