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War psychology research expands, troops found to suffer 'moral injuries'

As researchers and psychologists have come to a better understanding of post traumatic stress disorder a different kind of suffering among veterans has surfaced, a feeling of guilt or inner conflict called 'moral injury.'

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"There's no day — whether it's in the shower or whether it's walking down the street ... that I don't think about things that happened over there," says Kudo, now a graduate student at New York University.

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"Human beings aren't just turn-on, turn-off switches," Veterans of Foreign Wars spokesman Joe Davis says, noting that moral injury is just a different name for a familiar military problem. "You're raised on 'Thou shalt not kill,' but you do it for self-preservation or for your buddies."

Kudo never personally shot anyone. But he feels responsible for the deaths of the teens on the motorcycle. Like other officers who've spoken about moral injuries, he also feels responsible for deaths that resulted from orders he gave in other missions.

The hardest part, Kudo says, is that "nobody talks about it."

As executive officer of a Marine company, Kudo also felt inadequate when he had to comfort a subordinate grieving over the death of another Marine.

Dr. Brett Litz, a clinical psychologist with the Department of Veterans Affairs in Boston, sees moral injury, the loss of comrades and the terror associated with PTSD as a "three-legged stool" of troop suffering. Though there's little data on moral injury, he says a study asked soldiers seeking counseling for PTSD in Texas what their main problem was; it broke down to "roughly a third, a third and a third" among those with fear, those with loss issues and those with moral injury.

The raw number of people who have moral injuries also isn't known. It's not an official diagnosis for purposes of getting veteran benefits, though it's believed by some doctors that many vets with moral injuries are getting care on a diagnosis of PTSD — care that wouldn't specifically fit their problem.

Like PTSD, which could affect an estimated 20 percent of troops who served in Iraq and Afghanistan, moral injury is not experienced by all troops.

"It's in the eye of the beholder," says retired Navy Capt. William Nash, a psychiatrist who headed Marine Corps combat stress programs and has partnered with Litz on research. The vast majority of ground combat fighters may be able to pull the trigger without feeling they did something wrong, he says.

As the military has focused on fear-based PTSD, it hasn't paid enough attention to loss and moral injury, Litz and others believe. And that has hampered the development of strategies to help troops with those other problems and train them to avoid the problems in the first place, he says.

Lumping people into the PTSD category "renders soldiers automatically into mental patients instead of wounded souls," writes Iraq vet Tyler Boudreau, a former Marine captain and assistant operations officer to an infantry battalion.

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