When combat stress comes home
There are roughly 2.5 million men and women in United States Armed Forces and National Guard. Each of them must take an oath to support and defend the Constitution of the United States.
In a courtroom or a legislative chamber, “defense” of the Constitution takes the form of argument and analysis; but for the men and women of the armed forces, “defense” requires a confrontation with mortal danger and, as we are increasingly discovering, the real possibility of debilitating psychological injury brought on by what they do as much as by what is done to them.
Even in our sophisticated age, mental health professionals struggle with what to call the condition that results from perpetrating, witnessing, or failing to stop actions that violate a person’s deeply held beliefs about acceptable behavior. This type of stress often develops in connection with the killing of civilians during wartime (either intentionally or by mistake) mass killings beyond any bounds of necessity, killing (or torturing) of prisoners without justification, and failure to prevent the death of comrades.
To some military leaders, the preferred term is “inner conflict” because it focuses on the subject as a psychological matter but avoids any implication of immoral conduct. Mental health professionals tend to use the term “moral injury” because it is evocative and reflects the gravity of the conduct and the deep wounding of the individual based on a moral violation. Yet whichever definition applies, all Americans need to understand and appreciate the gravity of the problem, especially since it is the result of conduct undertaken in defense of our constitutional freedoms.
Recently two significant studies conducted jointly by the San Francisco VA Medical Center and the Department of Psychiatry at the University of California, San Francisco, have produced support for the theory that killing has a significant impact not only in producing psychiatric disorders like PTSD and depression, but in causing suicidal thinking and the desire for self-harm. There is special significance to the increasing awareness of this concept. In the words of the researchers, “prevailing models of posttraumatic stress have focused primarily on the experience and aftermath of severe deprivation, victimization, and personal life-threat, all of which can be experienced by soldiers in a war zone.” But that is only what you might call the “passive” experience of combat — what soldiers, in a sense “receive” from their situation. The studies show that it is just as important to understand the injury brought about by the “active” or “willful” combat experience – what soldiers do or do not do in the course of battle that may well leave them with this sense of “inner conflict” or “moral injury.”
The results of these studies should have serious implications for political and military leaders who attempt to justify the killing that soldiers are called on to do in combat situations. Whereas the risks of combat are well known and are intertwined with timeworn concepts of “courage,” “sacrifice,” and “patriotism,” the picture of soldiers emerging from battle suffering from PTSD, depression and suicidal thinking because of what they did or failed to do produces no such images. In fact, historically, such expression has been dismissed out of hand as cowardice.
The first study, published in 2009, examined veterans’ experience in situations involving killing as well as the relationship between killing and various mental health and functioning problems after returning to civilian life. The second study, published this year, carried the research to a different level. It looked at veterans of Operation Iraqi Freedom (OIF) by adding the component of suicidal thinking and the desire for self-harm to the relationship of killing in combat and mental health symptoms. While already noting that suicide rates among veterans of OIF and OEF (Operation Enduring Freedom) have escalated during these wars, the researchers found that suicide risk is even greater for veterans with mental health disorders including PTSD, depression, and alcohol abuse. In 2008, suicides among active-duty soldiers climbed to the highest point in 28 years, surpassing the rates among civilians with similar demographics.
Finally, it is important that our criminal justice system consider the implications of these studies with respect to understanding violent criminal behavior by veterans after they return home from combat. The simple answer is that we do not yet know what role combat stress plays as an inducement to criminal violence. Still, this much has to be considered: while the researchers envision their findings as being important in developing better methods of evaluation and treatment of newly returned service members, they should also become required reading for political and military decision-makers who commit young men and women to battle.
Barry R. Schaller, a retired Justice of the Connecticut Supreme Court and a Clinical Visiting Lecturer at the Yale Law School, is the author of the forthcoming Veterans on Trial, to be published in the spring of 2012.