The Unrecognized Invisible
Wound from Military Service
Post-Traumatic Stress Disorder (PTSD), traumatic
brain injury (TBI) and major depression have all been
identified as invisible wounds of the Iraq and Afghanistan
Wars. Despite the improvements
in treatment
interventions for PTSD over
the last decade, many veterans
are not responding to the
latest pharmacological and
psychological approaches.
There is also concern over
the rise in suicide rates both
in active duty and Veteran
populations. An additional
factor that remains unrecognized
and unaddressed is
Moral Injury. Moral Injury
is not a new term as it was
first identified by Jonathan
Shay in his 1994 book, “Achilles in Vietnam”.
Researchers describe moral injury as a breach of a
person’s ethical code that inflicts lasting behavioral,
emotional, and psychological damage. This “wound
to the soul” most often occurs when individuals commit,
fail to prevent, or witness an act that cuts against
their moral beliefs (Kutz, 2019). This can happen
either through an act (perpetrator) or failure to act
(silent witness) in war or garrison incidents, and/or
can result from abuse, threats, or betrayal (victimization,
e.g., by peers or chain of command) while serving
in the military. Other examples include decisions
that result in catastrophic loss, such as survivor’s guilt
or torturing/killing the enemy, civilians, or children;
being a survivor when others have died can leave lifelong
scars.
According to the VA, PTSD is a “mental disorder that
requires a diagnosis” while moral injury is considered
a “dimensional problem” with no definable threshold
for its presence. PTSD is a fear- based disorder that
causes functional disability: hyper-arousal/irritability,
avoidance, emotional negativity/numbing, and intrusive
nightmares/flashbacks. Moral injury is accompanied
by feelings of guilt,
shame, self-condemnation,
loss of trust, loss of meaning,
and spiritual struggles.
Its impact can change the
trajectory of relationships
and of one’s behavior, work,
and adjustment into civilian
life. It can also lead to questioning
of one’s character
and worth. Until resolved,
these internal conflicts can
in turn exacerbate social
problems (e.g., isolation,
aggression, legal issues) and
mental health symptoms
(e.g., anxiety, depression, PTSD, substance abuse,
suicide risk).
An estimated 11% to 20% of the 2.7 million men and
women who deployed to Iraq and Afghanistan have
received a PTSD diagnosis linked to their military
service. A study last year showed that 9 in 10 veterans
diagnosed with PTSD also exhibited at least on symp-
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