Posting #8: Stories about the invisible wounds of war

Dear Friends of SoldierGirl,

At the suggestion of several readers, I have decided to make my SoldierGirl postings bi-weekly instead of weekly.  This new “cadence,” as one of my readers has so aptly called the frequency of my postings, will give you more time to read and digest my postings and will give me more time to research and write them.

I will still be posting on Wednesdays at 6 am and the posting still will be sent directly to your email Inbox.  But you can expect the posting after today’s—October 18—to appear on Wednesday, November 1 and the following one on Wednesday, November 15.

More and more as I write these postings, I think we Americans need to know better how our military is constituted and operated.  Not only do we as taxpayers fund the Department of Defense, it is deployed in our name.  Thank you for your continued interest in this understanding!

Brenda

One of the leading war stories told in the United States is a two-parter.  First, the war is not only justified, but it is also necessary.  As the world’s best hope, we are its savior, duty-bound to intervene wherever injustice and threats to freedom exist.  The second part of the story says that our combatants are revered for their protecting the rest of us, heroic during their tours of combat, and feted with parades and medals on their return from the battlefield.  They expect the happy reverence, heroism, and celebrations and we expect these things, too.

But aside from the contradiction in the story—that the United States simultaneously is being passively protected as it offensively invades—and aside from the rarity of the story’s happy outcome, the story also almost never accounts for the woundings incurred by battle, wounds that can be physical, psychological, and sometimes lifelong.  If a servicemember is physically wounded in the story, it’s invariably a part of his (and I use this pronoun deliberately) acting heroically.  He selflessly and valiantly endangers his own well-being for the sake of his buddies, whether he is throwing himself onto a live grenade, pulling a wounded comrade off the battlefield and into safety, or flying a helicopter into heavy combat to evacuate wounded troops.  Rarely does the story include a wounding because of stupidity, “friendly fire,” or fearful refusal to engage in combat.

The “invisible wounds,” however, the psychological ones, tend to be ignored and discounted and often stigmatized, maybe because their invisibility makes it harder to depict them in film, the way I would wager most Americans are exposed to war stories.  Mostly, though, I think the psychological wounds are overlooked/ignored because their very existence threatens the predominant standards of masculinity expected of American males and particularly American servicemembers. At minimum, that standard includes boundless courage and fearless patriotism.  If a male’s psyche is disturbed by what is believed to be natural to a male—testosterone-driven fighting—the disturbance surely must be because something is wrong with him, not with the circumstances in which he finds himself.

Most of American history reflects this conclusion, that fragile male psyches pre-exist war and are not caused by it.  It was not until 1980, well after 1973’s conclusion of the American war in Viet Nam, that Post-Traumatic Stress Disorder (PTSD) was formally recognized as a legitimate diagnosis and has since become a household term.  The radical change represented by this diagnosis meant that servicemembers were not, as previously thought, predisposed to psychological ill health in war but instead, war should be expected to make its participants mentally ill.  Attitudes about “malingerers” and “hysterics” and “neurotics” did not immediately change, though.  One hundred and fifty years of American war compounded by American conceptions of masculinity have made it difficult to unleash holding individual combatants responsible for their wounded psyches.

In the American Civil War (1861-1865), before the advent of modern psychiatric medicine, there were two ways to explain the alterations to soldiers following the war.  The first was physical, termed “soldier’s heart.”  It was a literal term, not metaphorical, and so described the physiological changes to a soldier’s post-war heart functions: blood pressure, pulse, and propensity to heart attack.  The second was psychological and termed “nostalgia.” This concept existed during the war and was used to shame poor-performing soldiers.  It was attributed to “’feeble will,’ ‘moral turpitude’ and inactivity in camp. Few sufferers were discharged or granted furloughs, and the recommended treatment was drilling and shaming of ‘nostalgic’ soldiers—or, better yet, ‘the excitement of an active campaign,’ meaning combat.”  While from today’s vantage point, a lot of the behaviors of combatants then resemble what we now call PTSD, at the time, soldiers were held personally responsible for their “unnatural” response to war.

By the July 1914 beginnings of World War I (1914-1918), psychiatry had been born. The most well-known among the turn-of-the-19^th century psychoanalysts was Sigmund Freud, whose theory that conflicts in the psyche are what lead to pathology, or mental illness, fortified the notion that soldiers were individually responsible for their responses to combat.  By mid-1917, when the first American soldiers arrived in Europe to engage in combat, “shellshock,” also known as “war neurosis” and sometimes “hysteria,” was an accepted diagnosis for the large numbers of men suffering from constant artillery bombardment, indiscriminate use of chemical agents, and trench warfare.  Nonetheless, the treatment emphasis was on restoring a male’s natural masculinity: “even the most sophisticated psychological approaches developed to deal with shell-shock drew heavily on [masculine] concepts of self-control, self-reliance, and strength of character.”

Before the arrival of the American troops, however, an American physician sent to Europe to assess how the British and French were treating shellshock concluded that it was men predisposed to trauma and inherently weak who were experiencing the neurosis.  Consequently, he recommended mental illness screening of all male recruits to preclude their being affected by shellshock and consequently lessening the power of US forces.  (Keep in mind that “mental illness” then could include any number of conditions that have subsequently been debunked as neuroses, including homosexuality, degeneration (and its solution, eugenics), learning disabilities, and the age-old accusation of faking illness.)

World War II (1939-1945) began with Germany’s September invasion of Poland.  France and Great Britain subsequently declared war against Germany, and, more than two years later, the United States joined their alliance after Japan attacked Pearl Harbor in December 1941 and the European Axis powers declared war against the United States.  As in World War I, it was thought that men already susceptible to becoming a psychiatric casualty could be screened out before they were drafted, with the same “mental illness” diagnoses persisting since WWI’s ending only a couple of decades earlier. Though the psychological effects of the war were still thought to pre-exist wartime, the effects were termed differently. “Combat fatigue,” “exhaustion” or “stress” was based on a hypothesis that mentally healthy men could endure combat chaos for up to 240 days without suffering psychologically.  Late in the war, however, and after multiple intense campaigns in Italy and France, military medicine concluded that “Practically all men in rifle battalions who are not otherwise disabled ultimately became psychiatric casualties.”  Of the million-or-so men who experienced direct combat during the war, “More than half a million service members suffered some sort of psychiatric collapse due to combat. Alarmingly, 40 percent of medical discharges during the war were for psychiatric conditions. The vast majority of those can be attributed to combat stress.”  All indications were that there was something about war that caused this breakdown, but the conclusion instead was that mental illness was more widespread in American society than predicted: “this reinforced the view that mental illness was very prevalent in American society. A number of military psychiatrists also began speculating that the sort of stresses experienced by soldiers could be paralleled by stresses that affected civilians. The task of tackling civilian mental illness would be just as daunting.”

Some background to what is known in Viet Nam as the American War (1965-1973) is needed here, since it impacts how American soldiers would psychologically respond to war there.  In this period, the assumption persisted that if they were psychologically wounded at war, they were weak or predisposed to mental illness.

Although the United States had been financially aiding France in its post-World War II recolonization war in Viet Nam, in 1954 the United States replaced France as the dominant power.  A condition of France’s failure in the war and surrender was that the country temporarily would be partitioned into North and South, with France’s nemesis, the Viet Minh, assuming control of the North and the newly-formed State of Vietnam controlling the South.  Country-wide elections were supposed to follow and determine the nation’s ability to govern itself.  Fearing the “domino effect”—that if the Viet Minh communist forces gained control of the entire country with Ho Chi Minh likely being elected, more countries would subsequently “fall” to communism—the United States committed to militarily supporting the State of Vietnam.  Consequently, the election was not held and the two parts did not unite. Several years of further support—without (yet) the commitment of full American combat units—continued.

Following President Kennedy’s November 23, 1963 assassination (and the assassination three weeks earlier, November 2, 1963, of the State of Vietnam’s leader, Ngo Dinh Diem), Vice President Lyndon Baines Johnson assumed the presidency.  Embracing the “domino effect,” he continued the escalation of American military commitment started by JFK, though stopped short of actually declaring war against North Viet Nam.  In fact, though war never was declared, American combat troops landed on the beaches of the State of Vietnam in March, 1965.

Conscription had been in place since 1940, but by 1964 it had become a bone of contention because it exempted both men who were in college and also could access medical disqualification.  Until the draft lottery began on December 1, 1969, men could seek college deferments and other medical disqualifications still held (like poor eyesight, bone spurs, and homosexuality), making it easier for better-connected men to evade the draft.  The lottery was meant to even the playing field, but it was not perceived as accomplishing that and so anti-war protests continued across the country.

Consequently, there was a list of grievances already creating bitterness and resentment about the war, especially among the 18–26-year-old men who were draft-eligible:

·      War was never declared (nor has it been since World War II);

·      On a poor, small, developing country that the United States tried to have re-colonized;

·      And the draft persisted, even though war had not been declared;

·      And men of privilege could be exempted from the draft, even once there was a lottery.

Just as in World Wars I and II, men were screened for a predisposition to mental illness and were treated near combat for psychological wounds.  Nearly a quarter of all troops deployed to Viet Nam “required some form of psychological help.”  One might conclude that it was the specifics of the Vietnam War that made men susceptible to psychological woundings.  Still, it was in 1980, years after the Vietnam War had concluded in 1973 that clinicians realized that predisposition to mental illness mattered less than being in war itself. 

This is the radical shift that Post-Traumatic Stress Disorder (PTSD) represents: that the four symptoms associated with the fearful effects of trauma in war are a normal response in such a contentious conflict.  One of the first clinicians to study the psychological effects of the war reports that “the questionable character of the war in all likelihood will contribute to the occurrence of PTSD, because there is not the buffering factor of feeling that despite the difficulties one has encountered, there is at least a sturdy justification for what one has experienced.”  This comment suggests that it was the particulars of this war that created trauma-inducing conditions. 

Now we know that 70-75% of Vietnam War veterans have never suffered from PTSD, but more than 250K still struggle with the condition, 50 years after the war’s end. We also know:

·      that PTSD symptoms can be delayed and chronic despite the during-war efforts to prevent “psychiatric casualties”;

·      that veterans who served during the Vietnam War era but not in Viet Nam, Laos, or Cambodia do not experience PTSD at nearly the same rates as veterans who served in those countries;

·      that since the diagnosis of PTSD became available in 1980, beginning in the 1990s there has been a significant number of veterans from WWII who are seeking treatment for PTSD;

·      And finally, we know that “one in six Iraq veterans and one in nine Afghanistan veterans suffered from PTSD.” 

With combatants from wars previous to and following the Vietnam War having been diagnosed with PTSD, we can conclude that it was not, after all, the particulars of the Vietnam War that set the stage for trauma but that war itself induces psychological wounds.

So what?

The birth of PTSD as a predictable and normal outcome of war demonstrates that we have so much to learn about the “invisible wounds” of war and that we need to figure them into the decisions to go to war in the first place.  The wars in Afghanistan (2001-2021) and Iraq (2003-2011) have produced signature physical woundings like Traumatic Brain Injury and the horrific outcomes of exposure to toxic burn pits.  They have also reproduced the psychological wound of PTSD and have brought more attention to a not-so-new category of invisible wound, Moral Injury.

The Lancet describes the difference between the two conditions:

Unlike post-traumatic stress disorder, which can occur following threat-based trauma, potentially morally injurious events do not necessarily involve a threat to life. Rather, morally injurious events threaten one's deeply held beliefs and trust. Moral injury is not considered a mental illness. However, an individual's experiences of potentially morally injurious events can cause profound feelings of shame and guilt, and alterations in cognitions and beliefs (eg, “I am a failure”, “colleagues don't care about me”), as well as maladaptive coping responses (eg, substance misuse, social withdrawal, or self-destructive acts). It is these challenged beliefs and altered appraisals that are thought to lead to the development of mental health problems.”

In short, rather than the external fear or threat that elicits PTSD, internal shame and guilt yield Moral Injury.

Moral injury is the damage done by war when what servicemembers do—or don’t do—injures their moral code, their sense of self, a condition that the Veterans Administration acknowledges.  Veterans from the American wars of at least the last 75 years report this shame and guilt.  In Beyond PTSD: The Moral Casualties of War, Vietnam War veteran and philosopher Camillo Mac Bica ascribes Moral Injury to the post-World War II determination that only about 25 percent of combatants in that war fired their weapons to kill, and that subsequent US military training was “aimed at destroying or overriding their [combatants’] moral aversion to killing” (63).   This “moral identity confusion,” he continues, was “exacerbated by the modern warriors’ increased willingness to kill” (83).  

Afghanistan War veteran Timothy Kudo writes in a 2018 collection about moral injury that “It’s not the sights, sounds, adrenaline, and carnage of war that linger.  It’s the morality.  We did evil things, maybe necessary evil, but evil nonetheless” (79).  In the same collection, Iraq War veteran Tyler Boudreau attributes his moral injury to the American “occupation” of Iraq, as opposed to “war.” To draw the distinction, Boudreau conjures the heroic scenes I’ve described at the opening of this essay.  “It’s easy to imagine the famous battles of the past in the trenches, and the beaches, and the mountains, and the jungles, all of them covered with corpses and steeped in blood.  The American consciousness has been imbued with these images through every mode of popular culture.  But occupations look much different” (55-56).  Douglas A. Pryer, one of the two editors of the collection and a retired US Army officer, served in both Iraq and Afghanistan, and in 2003, was partly responsible for “interrogation operations” for the Baghdad area.  This included Abu Ghraib prison, to which Pryer had former prisoners sent for questioning.  Though he never received any “actionable intelligence” from the “enhanced” interrogations, he persisted sending the prisoners, unsuspecting of the torture and abuse being inflicted by Americans on Iraqis.  “Many American soldiers feel tainted by what happened at the prison.  I suspect I feel tainted more than most.  It makes me nauseous to think that, by…asking for certain prisoners to be interrogated, I was probably part of a causal chain that led to the torture of other human beings.  How could I have not understood what was happening?” (61-62).  Even Russian soldiers fighting in Ukraine complain of “moral exhaustion.”

A significant difference between PTSD and Moral Injury is how they are expected to be treated.  Whereas medical professionals are seen as responsible for treating PTSD, Moral Injury, it is claimed, must be treated by the society that sent men and women to war.

Clinical psychiatrist Jonathan Shay was the first to recognize a relationship between the two in his 1994 exploration of the parallels between veterans of the Vietnam War suffering from severe PTSD and the story of Achilles in Homer’s Iliad.   In Achilles in Vietnam: Combat Trauma and the Undoing of Character, Shay writes that “The essential injuries in combat PTSD are moral and social, and so the central treatment must be moral and social.  The best treatment restores control to the survivor and actively encourages communalization of the trauma” (187; emphasis added).  Nancy Sherman reiterates this lesson of communal responsibility in 2015’s Afterwar: Healing the Moral Wounds of Our Soldiers:

We have a sacred moral obligation to those who serve, whether or not we agree with the causes of the war and whether or not those who serve agree with them.  These moral obligations are institutional, both governmental and nongovernmental: veterans are morally owed the best possible resources across the widest swath of medical, psychiatric, social, legal, and technical services. But the obligations and expectations are also interpersonal, one-on-one.  We have duties to each other for care and concern: normative expectations and aspirations that we can count on each other, we can trust and hope in each other, and we can be lifted by each other’s support” (3).

PTSD dismissed the old belief that there was something wrong with the mental fortitude of men who were adversely affected by war.  This is a historically radical notion, that the inevitable trauma of war causes the invisible wound of mental illness.  Moral Injury builds on the idea that there is a causal relationship between war and invisible combat injuries, injuries that endure and for which we citizens are responsible.

The two parts of the story we Americans tell ourselves rely on the war being justified and the war producing heroes.  If neither justification nor heroism are confirmed, and instead our troops return as physical and mental casualties, how can we possibly permit our elected representatives to continue sending our men and women into combat?  Are we not morally injured when, knowing how our troops will inevitably suffer the invisible wounds of war, we agree to send them as our combat emissaries?