Shame and Moral Injury in an Operation Iraqi Freedom Combat Veteran

Street Fight, by SFC Elzie Golden, courtesy of the Army Art Collection, US Army Center of Military History.

Posttraumatic stress disorder (PTSD) frequently develops in military combat veterans. Though symptoms broadly resemble PTSD that develops in civilian settings, the different index traumas and patient interpretations of those traumas have led to an increasingly recognized subset of this common disorder: moral injury . Gray and colleagues provided the following definition of moral injury: “a term used to describe a syndrome of shame, self-handicapping, anger, and demoralization that occurs when deeply held beliefs and expectations about moral and ethical conduct are transgressed [1].”

These beliefs and expectations, or “moral standards,” can be defined as “an individual’s knowledge and internalization of moral norms and conventions [2].” Conventions might be universal or culture specific. Generally, actions that cause adverse conscience experiences by other sentient beings get judged as “wrong,” such as interpersonal violence and stealing [2]. Within the military, the rules of engagement typically vilify directing violence towards noncombatants and other vulnerable individuals [2, 3]. In this chapter, we discuss the experience of one soldier who developed moral injury secondary to violations of his moral standards.

4.1 Case Presentation/History

The pseudonym Sergeant (SGT) Smith will be used for a 27-year-old married male soldier with no prior psychiatric history who presented with symptoms of posttraumatic stress after his second combat tour in Iraq. The service member was in his usual state of good psychological health through the first half of a 6 month deployment. At that time the enemy began utilizing adolescents as young as 10 years old to load and fire mortars onto his base during night operations. Everyone in his unit recognized this practice and minimized return fire to limit injuries to these child soldiers. However, given mission interference and the vulnerability of their position, occasionally engagement became necessary to prevent American casualties.

The patient recalled one specific encounter when he fired the round that killed a teenage boy. Reflexively, he experienced a rush of excitement and euphoria that frequently accompanied engagement in firefights. After that event, his operational tempo did not allow him further reflection on this incident.

Upon return from deployment, SGT Smith remembered the cardinal event vividly whenever he attempted to spend time with his 9-year-old son. He developed multiple psychological symptoms over the course of the following months, including irritability, anhedonia, withdrawal from his nuclear family, exaggerated startle, depressed mood, poor sleep onset, frequent nightmares, self-loathing, suicidal thoughts, and paroxysmal physiologic anxious symptoms, namely flushed skin, muscle tension, and bounding heartbeat. Suicidal thoughts occurred in the context of his intense persistent dysphoria and belief that he did not deserve to live.

These symptoms interfered with his occupational functioning. He could not tolerate large congregations of people and he considered separating from his wife because of the arguments they were having, which he attributed primarily to his shortened temper. He presented voluntarily for mental health treatment at the urging of his unit medical provider.

SGT Smith suffered no other medical conditions and denied family history of psychiatric disorders. He took no medications and had no known drug allergies. He grew up in the Midwest to an intact union with three older siblings. Growing up, his favorite activity was participating in team athletics. He enjoyed the structure, traditions, and uniforms that were integral to sports culture. Additionally, contributing to something larger than the sum of its parts provided him a sense of purpose.

He enlisted in the Army immediately after high school, in part to cultivate these tendencies. He abstained from alcohol and illicit drugs, and his military performance until symptom development had been excellent.

Mental status exam revealed a well-groomed soldier of average build and no psychomotor abnormalities. He displayed a dysthymic and restricted affect, poor eye contact, and only surface-level rapport with the provider. He admitted to passive death wishes, but had no active suicidal or homicidal thoughts. Routine screening lab results were normal.

4.1.1 Pearls

Be patient while gathering history. Portions of this individual’s history remained unrevealed even after several months of regular medication management appointments.

Become familiar with screening instruments available for moral injury. If suspected, consider administering the Moral Injury Events Scale or the Posttraumatic Cognitions Inventory [1, 4]. These instruments may help to characterize the contribution of moral injury to the service member’s presentation.

4.1.2 Potential Pitfall

Being perceived as judgmental towards the actions of combat veterans. Be aware that military combat stories might not be savory, but the perception of negative appraisal by a provider could cause him or her to flee. SGT Smith’s treatment course, detailed in following sections, illustrates this poignantly. Providing a sense of safety is one way to facilitate the therapeutic alliance, which seems to be particularly important treating individuals with PTSD [5].

4.2 Diagnosis/Assessment

4.2.1 Formal Diagnosis

The patient in this case exhibits all the classic PTSD symptom clusters, including avoidance, reliving experiences, and excessive physiologic hyperarousal. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) reiterates these core areas but splits avoidance symptoms into two separate phenomena: avoidance and negative cognitions/mood. Currently, avoidance narrowly applies to internal (“memories, thoughts, or feelings”) or external reminders of the traumatic event [6]. The category of “negative alterations in cognitions and mood” retains most avoidance symptoms that appeared in the text revision of DSM-IV, such as feelings of detachment and anhedonia 7]. However, critical features of this patient’s presentation were not attributable to PTSD based on previous diagnostic symptom lists. New criteria added in DSM-5 include persistent and exaggerated negative beliefs and a persistent negative emotional state [6]. SGT Smith’s self-loathing, negative mood, and negative self-perception grew out of shame for his actions and emotions experienced during combat, and can be accounted for without diagnosing another mental health disorder.

Despite the criteria modifications, available information and treatment recommendations for PTSD predominantly address symptoms as though they were caused from the intense fear associated with a life-threat incident. For instance, “fear situations” are systematically reevaluated using cognitive behavioral therapy (CBT) variants [1]. These variants include prolonged exposure (PE) and cognitive processing therapy (CPT), which are strongly recommended treatment protocols for PTSD [8]. Formulating cases with these cognitive models may be appropriate for most incidents resulting in PTSD in civilians.

Besides a perceived life threat, there are other recognized traumatic events that could precipitate symptoms, including significant loss of friends, bullying, chronic illnesses, killing, and exposure to malevolent environments [4]. Two things about SGT Smith’s history differ from many other mental health patients by his inclusion in a military subculture and killing behavior, which he identified as his most significant combat experience. Although PTSD remained the coded diagnosis, moral injury more accurately captures the syndrome with which he presents.

4.2.2 Moral Injury

Specifically for this patient, killing a vulnerable youth represented the transgression that violated his view of how the world should operate. Moral transgressions that are stable, internal, and global lead to enduring emotional symptoms of shame and anxiety [3]. When asked, SGT Smith reported that taking the life of a teenager made him feel persistently bad about his character (stable), “less than human” (internal), and was not excused despite the operational context (global). He primarily exhibited shame as a result of this morally injurious event.

4.2.2.1 Shame

DSM-5 combines the experience of shame and guilt in a single criterion, yet a consequential distinction should be made [6]. Guilt involves believing that one committed an improper action or feeling. Usually, there is remorse for acting or experiencing events in a certain way. Those actions or emotions are judged harshly, and often there is a desire to “make amends” for them. In contrast, shame involves making implications about oneself, or one’s own self-concept [9]. That is, the focus of negative assessment turns internally.

Shame and guilt are not mutually exclusive, though SGT Smith illustrates that they have the potential to exist independently. He did not regret his actions or feel a need to atone for them. If he had not returned fire his entire unit would have faced continuous and imminent lethal threat. However, the “pleasure” and “excitement” he reported during killing undermined his humanity. In his words, it “makes [him] no better than an animal.” His pre-deployment self-concept became negatively altered because of how he felt after firing a round that ended the life of a youth.

Combat veterans can be differentially susceptible to shame development and the subsequent severity of PTSD symptoms. For example, Leskela, Dieperink, and Thuras administered the Test of Self-Conscious Affect (TOSCA) and the Military PTSD Checklist (PCL-M) to former prisoners of war [9]. The TOSCA has been utilized to measure proneness for feeling guilt or shame, with “proneness” defined by Tangney et al. as the “propensity to experience that emotion across a range of situations [2].” Results indicated that shame-proneness was positively correlated with PTSD symptom severity [9].

In contrast, the same study found that when isolated from other factors, guilt-proneness was negatively correlated with severity of PTSD symptoms. Although not conclusive, this implies that the ability to experience guilt for specific actions allows individuals to cope by atoning for their actions through alternative means available to them, such as volunteer work or mentoring. SGT Smith’s shame has repercussions for his self-perception, and he did not feel that actions directed towards others might atone for his behaviors or earn forgiveness.

4.2.2.2 Killing

Military service members serving in combat missions bear the burden of participating in sanctioned killing. Killing is associated with multiple post-deployment problems. A study by Maguen and colleagues found that killing in combat is a predictor of relationship problems, alcohol abuse, and symptoms of PTSD [10]. Remarkably, when killing variables are controlled for, general combat experiences are not significantly related to PTSD severity in Vietnam vets [11]. This could imply that these behaviors mediate the severity of PTSD, not the sum of total combat exposure. Finally, in veterans with symptoms of PTSD or depression , a history of killing was associated with suicidal ideation [12]. These findings suggest a unique contribution of these behaviors to mental health problems.

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