Combat veterans who develop psychiatric disorders also might have a condition identified by researches as "moral injury." This state might arise after service members find themselves in situations they might find morally questionable or ethically ambiguous (Clin. Psychology Rev. 2009; 695-706) and in direct conflict with the way they live their civilian lives.
It is important for psychiatrists and other mental health professionals to address the lasting impact of acts that transgress moral beliefs and expectations, or moral injury. Failing to do so can lead to guilt, trauma, and sometimes, the ultimate sacrifice. The case of Marine Lance Cpl. Jeffrey Lucey painfully illustrates what can happen to our warriors.
Dreams become nightmares
Dr. Jamshid A. Marvasti
Jeffrey Lucey, a young man who lived in western Massachusetts, reportedly signed up to join the Marine Reserves in 1999, as a way to help his mother and father – a therapist –pay his college tuition. His unit was activated to Kuwait in 2003 and he ended up in Iraq.
After he returned home, Lance Cpl. Lucey told his family that he had been ordered to shoot two Iraqi prisoners and had kept their dog tags. The Marines reportedly investigated his claim and determined that the incidents he described did not happen. After episodes of heavy drinking, having nightmares, and talking about killing himself, his family called Veterans Affairs. According to some reports, Jeffrey Lucey was diagnosed at a VA medical center as having posttraumatic stress disorder (PTSD), in addition to depression with psychotic features and suicidal ideation, and acute alcohol intoxication.
Unnerved by Lance Cpl. Lucey’s behavior, his family removed items they deemed dangerous from the home. They say they hid dog leashes and got rid of combat knives. Lance Cpl. Lucey had crashed his parents’ car, and so they disabled his.
One day, Lance Cpl. Lucey’s father found that his son had hanged himself in the cellar. On his son’s bed, his father found the dog tags of the two unarmed Iraqi prisoners that Jeffrey Lucey said he had been ordered to shoot, according to reports. Some contend that the Marines advised members of Jeffrey Lucey’s unit not to talk with the news media.
Despite the U.S. government’s denials, it agreed to settle a wrongful death suit in 2009 filed by the young man’s parents alleging negligence. The case was settled for $350,000.
Alarming suicide rates
U.S. veterans commit suicide at a devastating rate of 22 people per day. Military statistics reveal that more soldiers committed suicide in 2012 than were lost in battle. (On a positive note, the Army reported recently that suicide rates for the active Army, the Army National Guard, and the Army Reserve declined, from 325 in 2012 to 301 in 2013.)
Two categories of military personnel might develop war trauma and suicidality. The first category involves those who have been traumatized by combat and the loss of their comrades. The second category involves those who participate in activities that they see as immoral – such as killing civilians or torturing prisoners. The latter category also is at risk of developing psychiatric disorders, with exception of those few people who are psychopaths.
Multiple researchers have shown that atrocities are associated with the development of PTSD and guilt. In a study of 1,323 male Vietnam veterans, researchers found that combat-related guilt mediated the connection between participation in abusive behavior during the war, and both PTSD and depression (Depress. Anxiety 2010;27:287-93).
Among a sample of 1,709 Vietnam veterans, researchers found that being a target of the attempts of others to kill or injure "is related more uniquely than any other role to symptoms that are diagnostic criteria for PTSD. They also found that being an agent of killing and failing to prevent someone else from dying or getting hurt proved more strongly tied to general psychiatric distress and suicide attempts (J. Nerv. Ment. Dis. 1992;180:748-55).
Other causes of ‘moral injury’
Some soldiers fought in the war against Saddam Hussein with the expectation of being welcomed as liberators. Furthermore, they expected to establish justice/democracy and then return as heroes decorated with medals. But these expectations have turned to disappointments. It can be potentially devastating when our veterans are labeled as "invaders" and "agents of imperialism" by civilians rather than as "liberators" and "creators of democracy."
In some cases, soldiers develop a moral injury when they are exposed to the devastating effects of their invasion on cities and their participation in civilian casualties. Such casualties are almost inevitable when one invades and bombs a populated city. Some soldiers feel as a sense of betrayal toward their commanders, and this is another cause of moral injury.