As a former Marine Corps Officer, Vietnam veteran, and philosopher with a focus in social and political theory and ethics, I have spent the last 40 years of my life studying and striving to understand the institution of war and its effects upon those who fight it. My ability to shift back and forth from the warrior to the philosopher, to introspect, re-experience and then to examine, unpack, and analyze, though at times extremely anxiety provoking, provides a unique perspective that has been advantageous to my philosophical research and, I dare say, to my healing.
In this article I will consider what has been accurately termed the "invisible wounds of war" and three perspectives on healing, e.g., the Clinical Model as set forth in the Diagnostic and Statistical Manual of Mental Disorders, which views the invisible wounds of war as mental illness; the Normal Response Model as elucidated by Paula J. Caplan, in her new book , When Johnny and Jane Come Marching Home: How All of Us Can Help Veterans, which views a veteran's "disturbed and lasting emotional response" to war as a normal response to an abnormal situation; and my C ombat Injury Model, where such injuries and veteran readjustment difficulties are regarded as the wounds of war, specifically Combat Related Psychological, Emotional, and Moral (PEM) Injuries. I will begin, however, by providing some background and relate an account of my coming home from war, which though personal, is, I am confident, not unlike many others who shared the experience.
The Warrior's Perspective: War's Aftermath
I remember thinking, amidst the insanity of the Vietnam War that one day this horror will end and I will put these experiences behind me, pick up where I had left off, and go on with my life. Like most young adults, I had expectations for what I wanted to do and to accomplish. Once I returned home, however, it soon became apparent to me that something had changed, or better, that I had changed. I realized that Vietnam had profoundly affected my life, that war takes its toll on body, mind, and spirit. I realized as well that America had little tolerance, interest, or understanding for its returning warriors. I was called a drug addict and baby killer by many in the general public and ostracized even by fellow veterans from previous wars for being a cry baby, a loser, for lacking dedication and effort, for disgracing the "uniform," ourselves, and the country by losing America's first war. This realization that I was alienated and alone and that no one seemed to understand or care about what I was undergoing, made me sad at first, soon to be followed by anger and resentment.
After several years of isolation and denial, trying to avoid "contaminating" friends and family and the stigma of being a Vietnam veteran, I was convinced by another vet to seek help at the Veterans Administration. Almost immediately, I was "assailed" by VA clinicians who "diagnosed" my inability to cope, alienation, nightmares, etc., as personal inadequacy and weakness probably due to some pre-existing condition, perhaps a personality disorder, maybe even schizophrenia. Most likely, they hypothesized, my difficulties had something to do with my mother being overweight or my being toilet trained too early. What was peculiarly absent from all this analysis, testing, and ad hominem attacks, however, was reference to the war. So I blamed myself for my weakness and my mother for her eating habits and for how she raised me, and resigned myself to the fact that, for all intents and purposes, at twenty-five my life was over. Was I crazy, a baby killer, a cry baby, a coward? Perhaps I was all of these. Needless to say, I wasn't very please with myself, with those around me, or with the fact that, other than a heavy regimen of Thorazine, what some refer to as a "chemical lobotomy," VA doctors and clinicians weren't offering much help and guidance. So it became apparent to me, that if I was to salvage what remained of my life, and I was not at all sure healing was possible, I needed to do it myself, to come to an understanding, perhaps even acceptance of what I had done and what I'd become.
After many years of struggle, of isolation, not knowing, of being demeaned by fellow veterans, and not taken seriously or misdiagnosed by the VA, you can imagine, I think, how vindicated many of us felt when the psychiatric community and its bible, the Diagnostic and Statistical Manual of Mental Disorders, recognized at last that our injuries were not merely a product of our imaginations or the result of personal weakness and cowardice. That they were real and legitimate, caused by our experiences in war, and that it had a collective name, Post Traumatic Stress Disorder (PTSD). Further, after years of suffering the deterioration and deaths of so many of our brothers and sisters, this recognition truly felt like victory, like progress. We thought, better we hoped, that we would no longer be ignored or misdiagnosed and now that the psychiatric community understands what we are up against, a cure will be forthcoming. And maybe, just maybe, with this realization of war's devastating effects on a generation of American youth, those with a propensity to initiate and support war will think long and hard before sending other children into harm's way. At least this is why many of us initially celebrated the recognition of PTSD and accepted joyfully and with a sense of optimism and relief, the diagnosis that we were mentally ill.
The Philosopher's Perspective: The Struggle to Heal
Over the history of warfare, the invisible wounds of war have been collectively referred to as "Soldier's Heart" during the Civil War," "Shell Shock" during World War One, "Battle Fatigue, and "Combat Exhaustion" during World War Two. Most recently, the designation has lost its poetics, been stripped of its reference to war and battle, and become rather clinical. Those psychologically, emotionally, and morally wounded as a result of their combat experience are instead given a diagnosis of Post Traumatic Stress Disorder. PTSD, according to the National Institute of Mental Health, is an anxiety disorder that can develop "after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened." Consequently, some thirty to thirty-five percent of veterans who have served in Vietnam, Iraq, and Afghanistan, are not combat wounded, but, rather, mentally ill.
There are those, however, who dispute the diagnosis and the pathologizing of the experience. In a recent and important contribution to the literature of war and healing, When Johnny and Jane Come Marching Home: How All of Us Can Help Veterans, Paula J. Caplan, a clinical psychologist and fellow at Harvard's Kennedy School, denies what she terms the "disturbed and lasting emotional response" of members of the military and veterans to war is mental illness. Rather, she favors a position similar to Victor Frankl who writes in Man's Search for Meaning, that "An abnormal reaction to an abnormal situation is normal behavior." Her concern is that to pathologize these "normal" responses "as a mental illness called Post Traumatic Stress Disorder (PTSD) rather than as experiencing a common ordinary, understandable, human response to war's horrors," is not only inaccurate but detrimental to veteran healing as it increases their alienation, lowers self-esteem, and damages self confidence. "Abundant research," she notes, "shows that social support -- not high-powered clinical approaches, but ordinary, compassionate connecting -- has enormous healing power." Consequently, Professor Caplan advocates what she terms the "Listen to a Vet" program, and argues that every one of us, even those, probably preferably those, without professional mental health training ("civilians"), can help "troubled" veterans heal merely by listening, understandingly, compassionately, and non judgmentally, to their stories and their experiences. To prepare civilians for an encounter with a vet, Professor Caplan spends a chapter (chapter six) of her book providing guidelines for how each of us can effectively and curatively listen.
The Clinical Model and the Moral Casualties of War
Over the past forty years or so, veterans have been subjected to a progression of diverse clinical psychiatric procedures for treating PTSD -- Psychotherapy, Pharmacological Therapy, Eye Movement Desensitization and Reprocessing, Cognitive Behavioral Therapy, to name just a few. Yet they continue to suffer depression, anxiety, guilt, alienation, etc., and exhibit high rates of suicide, alcoholism, drug addiction, homelessness, and violent crime. Tragically, as soldiers experience the horror and cruelty of war, especially urban, counterinsurgency war, the moral gravity of their actions -- displacing civilians, torturing, injuring, and killing other human being -- becomes apparent, veterans may suffer the consequences of acting in violation of their moral identity, the moral foundations by which we structure our lives. That is, soldiers suffer not only the effects of trauma, but moral injuries, i.e., debilitating remorse, guilt, shame, loss of self esteem, self respect, disorientation, and alienation from the remainder of the moral community. [1] Consequently, to subsume all invisible wounds under the PTSD umbrella, as mental illness, is misguided and fails to address the totality of the injuries veterans have suffered in war.
Whether we act rightly or wrongly, i.e., according to or in violation of our moral identity, will affect whether we perceive ourselves as true to our personal convictions and to others who share our values and ideals. Moral injuries are, in most cases, an inevitable consequence of the sophisticated manipulation and distortion, experienced during basic training, of the recruits' moral foundations -- their moral identities -- made worse by the profound moral confusion and distress they experience as the horror and insanity -- the reality -- of war becomes apparent and they are confronted by the realization of the moral gravity of their actions in combat. Moral guilt is, simply speaking, the awareness of having transgressed their moral convictions and the anxiety precipitated by a perceived breakdown of their ethical cohesion -- their integrity -- and an alienation from the moral community. Shame is the loss of self-esteem consequent to a failure to live up to personal and communal expectations.
The observation that some human beings become moral casualties because of their experiences in war is not new. Historically, many societies have recognized war's deleterious moral effects and required returning warriors to undergo elaborate atonement and purification rituals, i.e., quarantine, penances, etc. [2] These "therapies" provided the means and the opportunity to cope with the moral enormity of their actions in war. Tragically, the moral injuries of modern warriors, however, have been virtually ignored, overlooked, or disregarded by the conventional psychiatric community [3] operating as it does within a Nietzschean-Freudian-Scientific legacy that views ethical concerns as clinically irrelevant, i.e., "autonomous man" ought [to] feel no guilt "nor bite of conscience" for his actions. [4] Focusing, instead, upon stress and trauma, most moral symptoms presented by returning soldiers are either not taken seriously or assimilated under the diagnostic umbrella of Post Traumatic Stress Disorder. Consequently, the veterans receive the signal that an inability to forget, to put the war behind them, is either weakness or, perhaps worse, mental illness. Accordingly, veterans are advised to ignore what has occurred, to "de-responsibilitize," i.e., to neutralize their feelings by accepting the "naturalness" of their behavior on the battlefield, [5] and/or to undergo a myriad of conventional therapies intended to enable them to deal with the stress and trauma of their experiences. In either approach, moral considerations are, for the most part, irrelevant.
Unfortunately, in most cases, moral injury neither responds well to medication or traditional clinical therapies, nor can it be rationalized away. In fact, such methods, according to Robert Jay Lifton, tend to alienate the veteran still further. Speaking about returning Vietnam Veterans, Lifton writes,
"The veterans were trying to say that the only thing worse than being ordered by military authorities to participate in absurd evil is to have that evil rationalized and justified by the guardians of the spirit . . . The men sought out chaplains and shrinks because of a spiritual-psychological crisis growing out of what they perceived to be irreconcilable demands in their situation. They sought either escape from absurd evil, or, at the very least, a measure of inner separation from it. Instead, spiritual-psychological authority was employed to seal off any such inner alternative." [6]
Such "therapeutic" advice as "forget it," "live with it," "act as though it never happened, or "don't worry, it's quite normal for human beings to act that way in survival (abnormal) situations," does little to alleviate the veteran's moral pain and suffering.
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