Quite possibly the best article on moral injury I have read. Thanks to The Atlantic and to Maggie Puniewska.

Healing a Wounded Sense of Morality
Many veterans are suffering from a condition similar to, but distinct from, PTSD: moral injury, in which the ethical transgressions of war can leave service members traumatized.

MAGGIE PUNIEWSKA JUL 3, 2015

Amy Amidon has listened to war stories on a daily basis for almost a decade.

As a clinical psychologist at the Naval Medical Center in San Diego, she works with a multi-week residential program called OASIS, or Overcoming Adversity and Stress Injury Support, for soldiers who have recently returned from deployments. Grief and fear dominate the majority of the conversations in OASIS: Amidon regularly hears participants talk about improvised explosive devices claiming the lives of close friends; about flashbacks of airstrikes pounding cities to rubble; about days spent in 120-degree desert heat, playing hide and seek with a Taliban enemy. Many veterans in the program are there seeking treatment for post-traumatic stress disorder.

But many of Amidon’s patients talk about another kind of trauma, a psychic bruise that, unlike PTSD, isn’t rooted in fear. Some of these soldiers describe experiences in which they, or someone close to them, violated their moral code: hurting a civilian who turned out to be unarmed, shooting at a child wearing explosives, or losing trust in a commander who became more concerned with collecting decorative pins than protecting the safety of his troops. Others, she says, are haunted by their own inaction, traumatized by something they witnessed and failed to prevent. In 2012, when the first wave of veterans was returning from the Middle East, these types of experiences were so prevalent at OASIS that “the patients asked for a separate group where they could talk about the heavier stuff, the guilt stuff,” Amidon says. In January 2013, the center created individual and group therapy opportunities specifically for soldiers to talk about the wartime situations that they felt went against their sense of right and wrong. (Rules of engagement are often an ineffective guide through these gray areas: A 2008 survey of soldiers deployed at the beginning of the conflict in Iraq found that nearly 30 percent of the soldiers in each group encountered ethical situations in which they were unsure how to respond.)

Experts have begun to refer to this specific type of psychological trauma as moral injury. “These morally ambiguous situations continue to bother you, weeks, months, or years after they happened,” says Shira Maguen, the mental-health director of the OEF/OIF Integrated Care Clinic at the San Francisco Veterans Affairs Medical Center and one of the first researchers to study the concept. Examples of situations that might precipitate moral injury are betrayals by those in leadership roles, within-rank violence, inability to prevent death or suffering, and hurting civilians. Sometimes it co-exists with PTSD, but moral injury is its own separate trauma with symptoms that can include feelings of shame, guilt, betrayal, regret, anxiety, anger, self-loathing, and self-harm. Last year, a study published in Traumatology found that military personnel who felt conflicted about the “rightness” or “wrongness” of a combat situation were at an increased risk for suicidal thoughts and behavior afterwards, compared with their peers who didn’t have that same sense of ambiguity. The main difference between the two combat-induced traumas is that moral injury is not about the loss of safety, but the loss of trust—in oneself, in others, in the military, and sometimes in the nation as a whole.
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