“I was born in the 40’s, grew up in the 50’s and DIED in the 60’s.” These are the words of a Marine veteran who served in Vietnam from 1968 to 1969. The trauma he experienced and the moral injury he suffered have been his daily companions for almost 50 years. In the following pages I will delve into the issues that both trauma and moral injury create, including suicide, and the methods being employed to help heal those who are suffering the effects of these injuries, often decades later.
The Vietnam War
The War fought in Vietnam from late 1955 to the fall of Saigon on April 30, 1975 was a long, costly armed conflict pitting the communist regime of North Vietnam and its southern allies, known as the Viet Cong, against South Vietnam and its principal ally, the United States. The divisive war, increasingly unpopular at home, ended with the withdrawal of U.S. forces in 1973 and the unification of Vietnam under Communist government control just two years later. More than 3 million people, including 58,000 American soldiers, were killed in the conflict over the course of those 20 years. In 1968 the US Troop strength peaked at 543,482 as a result of President Johnson’s troop escalation. The number of soldiers and the degree to which they suffered PTS and moral injury is a subject that has been studied for decades. Many of these soldiers returned to the US and got on with their families and careers. It wasn’t until they started to retire in the last decade that many long-buried issues arose and the scars they created on their psyche became evident. Of the reported suicides within these last 10 years among veterans almost 70% are within the age of having served in the Vietnam War. This is not to say that the wars since have been less damaging, just that the full effects can take decades to surface. The author Penny Coleman addresses this in her book Flashback:
In a discussion about the war in Vietnam and PTSD, we must also address a separate aspect of postwar amnesia: the relationship between PTSD and suicide in combat veterans. Once again, in history we find the origins of American attitudes toward suicide, which help explain the silence and shame that surround the act, silence and shame that have colluded in the official denial of the relationship of suicide to PTSD, thereby allowing an epidemic of self-inflicted deaths to go unseen. (p.3)
Silence and especially shame will be issues I will address a little later but I believe it’s important to look a little more deeply at PTSD and its relation to suicide. Bob, an Army combat veteran, wrote: “My PTSD is a vicious, terminal parasite...Its darkness began to advance, ravaging me, especially emotionally, robbing me of any ability to exist. Hopelessness, helplessness, and utter defeat of all that was human inside of me followed….PTSD took away the only life I knew. All that remained was my excruciating, inescapable mental agony and an insatiable search for any means to arrest it.” (Beder, p.157) Just after writing this he attempted to take his life but thankfully was not successful. It is no wonder that those who have been to war, seen death and destruction and been a part of 3 that would see that the only way out of those horrific memories was through their own violent end. The depression, anger, sleeplessness and anxiety the trauma creates can lead a strong-willed sane person to suicide - a permanent solution to a temporary problem. But by addressing the trauma we can work towards a meaningful and lasting solution.
Growing up we learn certain values, ethics and standards that help to form our morality. When a soldier goes to war those morals are challenged by the acts he is asked to commit and witness. The difference between PTSD and Moral Injury (MI) is “...sorrow, remorse, … bitterness, and moral confusion---What is right?---signal moral injury, while flashbacks, loss of memory, fear, and a startle complex seem to characterize PTSD” (Wood, p.17). I like to think of it as similar to the difference between shame and guilt. Guilt as PTS is something “I did or experienced” whereas shame and MI are “I am”. Not that both don’t haunt the body and soul, it’s just that MI seems to dig deeper into the sufferer and require different approaches to treat. Timothy Wilson in his book, Redirect: Changing the Stories We Live By, writes about the father of positive psychology Martin Seligman who with his “colleagues developed a program to increase resilience among soldiers using the principles of positive psychology, which attempts to increase human strengths and flourishing, rather than waiting for mental health problems to develop and then treating them” (p.244). These programs work for both PTS and MI but are better utilized as preventative measures before the symptoms set in. David Wood describes in the beginning of his book What Have We Done the story of a chaplain that utilized a baptismal font to do a symbolic warrior cleansing before the soldiers in his unit returned home to Pennsylvania from Iraq. They wrote on a piece of paper what they wanted to leave behind - “Things you have done and left undone...things you have seen.” Then their papers were set aflame. This was his adapted ceremony of healing and forgiveness so they could leave behind the moral wounds they had suffered. (Wood, p.5) When soldiers returned from Vietnam they were met by a public largely against the war that they had been drafted to go to. Very few volunteered and so I believe the moral injury was not only doubled but buried deeper. Recently at a screening of a documentary called “Almost Sunrise”, which documents two Iraqi veterans’ healing trek from Milwaukee to Los Angeles, one of the veterans told a story to the Marine I quoted at the beginning of this paper, about the great encouragement the two of them had received from Vietnam vets during their journey of healing. The Vietnam vets understood how important it was to unearth the issues as soon as possible so that the younger vets wouldn’t have to suffer, as they had, through decades with the PTS and moral injuries. This was a touching moment and a cross-generational healing moment I was honored to be witness to. But along with peer to peer support I believe we need to do more than just a “thank you for your service” token appreciation. I agree with Brene Brown who writes in Daring Greatly: “What I am advocating is a kinder, gentler public, one willing to embrace, support and reach out to the men and women we pay to be invulnerable on our behalf.”(p.156) Yes, war is inherently a divisive issue but respecting and honoring those who have served with methods to heal their wounds, I believe, is crucial to creating peace. While this quote references a child’s trauma, I believe it speaks too much of what Vietnam veterans experienced. Bessel van der Kolk writes in The Body Keeps the Score, “It is one thing to process memories of trauma, but it is entirely an different matter to confront the inner void---the holes in the soul that result from not having been wanted, not having been seen, and not having been allowed to speak the truth.” (p.298) We have done a great deal of the work necessary towards helping veterans speak their truth, for as Shakespeare writes in Macbeth, “Give sorrow words: the grief that does not speak knits up the o’er wrought heart and bids it break.” Too many Vietnam veterans have had their hearts broken and worse. The years they have suffered like the Marine I quoted at the start have many roots, but resolving moral injury issues is crucial. What of shame and its relation to finding forgiveness to heal the Moral Injury buried deep. Thelma Bryant-Davis writes in her book Thriving in the Wake of Trauma that “shame is the feeling of internalized ‘badness’ and general negative self-concept that the survivor has. It is not simply guilt over doing something wrong. Instead, it is the belief and feeling that at the survivor’s core that something is wrong. Shame creates feelings of embarrassment and causes the survivor to feel the need to hide.”(p.61) This is yet another aspect of how MI gets repressed, over decades, and requires years of effort to resolve. Shira Maguen, a therapist in San Francisco, has a program she calls “impact of killing” therapy. In it she explores with her “patients the emotional and physiological impacts of killing, then deals directly with self-forgiveness. Many veterans are resistant, believing that to forgive is dishonorable, dismissing a wrong they had committed.” She states that an important “part of self-forgiveness is understanding the context in which this happened, usually a situation where you are constantly making life-and-death decisions quickly without having all the information.” (Wood, p.253) In coming out of the shadows and finding their freedom from the shame and buried MI that they have lived with for decades, they are able to find their peace in self-forgiveness. Finally, there are a number of additional therapies being utilized with veterans in the search for healing and wholeness. Every week I attend an outpatient PTS “Expressions Group” where veterans read poetry, tell jokes, play musical instruments, talk about their healing journeys, sing or paint beautiful pictures. Many also find healing in just attending the group and being of service to those in the group. There is also an inpatient unit in the same building and they have a recreation therapist who utilizes art and equine therapy to help clients find healing. I do a weekly “garden group” where we practice horticulture therapy in the service of finding their soul in the soil. Additionally, I offer them information about education and careers in agriculture because it has been demonstrated that veterans are a great fit for farming. It can become their new mission to work towards greater food security in our country while also discovering the healing they find in the act of planting, caring for and harvesting locally grown food. Our war in Vietnam is over 5 decades old and has left us many wounds in need of healing. Issues of PTS and Moral Injury are crucial to address not only for those who acquired them in that Southeast Asian country but for the more recent veterans who have the opportunity to find health and healing now. Michael Castellana, a therapist at Camp Pendleton, says of veterans:
These are remarkable, courageous men and women. We should laugh with them, grieve with them, and most of all, empathize and inject a human perspective on the terrible experiences these service members have endured. We must bear with them, the distressing and challenging events they have lived through, and accompany them as they make their way to a new, fuller understanding and appreciation of their role in war and as fellow human beings in the world. (Wood, p.268)
It is crucial that we as individuals find ways to accompany them in their quest for healing, not only to stem the tide of trauma and violence already inflicted, but as acts of prevention so that the wounds suffered don’t beget new ones. With compassion and understanding, we can work to unravel both the PTS and Moral injury that many veterans have known for far too long, and in turn learn how to better address these issues in the future.
Beder, Joan ed. Caring for the Military: A Guide for Helping Professions. New York: Routledge, 2017. Brown, Brene. Daring Greatly. New York: Avery, 2012. Bryant-Davis, Thelma. Thriving in the Wake of Trauma: A Multicultural Guide. Westport, CT.: Praeger Publishers, 2005. Coleman, Penny. Flashback: Post-Traumatic Stress Disorder, Suicide & the Lessons of War. Boston: Beacon Press, 2006. Levine, Peter A. In an Unspoken Voice: How the Body Releases Trauma & Restores Goodness. Berkeley: North Atlantic Books, 2010. Meagher, Ilona. Moving a Nation to Care: Post-Traumatic Stress Disorder & America’s Returning Troops. Brooklyn, NY: Ig Publishing, 2007. Van der Kolk, Bessel. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York: Viking, 2014. Wilson, Timothy D. Redirect: Changing the Stories We Live By. New York: Back Bay Books, 2011. Wood, David. What Have We Done: The Moral Injury of Our Longest Wars. New York: Little Brown, 2017.