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The Invisible Wounds of War

Monday, 24 October 2011 08:28 By Camillo Mac Bica, Truthout | Op-Ed

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 on 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, for example, 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 combat 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. Although it is a personal story, I am confident it is not unlike the stories of many others who shared the experience.

The Warrior's Perspective: War's Aftermath

I remember thinking amidst the insanity of the Vietnam War, "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 crybaby and a loser, for lacking dedication and effort, for disgracing the "uniform," ourselves and the country for contributing to what was widely regarded as America's first lost 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 after that sadness was replaced 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 (VA). Almost immediately, I was assailed by VA clinicians who "diagnosed" my inability to cope, alienation, nightmares, etcetera 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 and testing and the ad hominem attacks, however, was any 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 25, my life was over. Was I crazy, a baby killer, a crybaby, a coward? Perhaps I was all of these. Needless to say, I wasn't very pleased 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 going 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 an acceptance, of what I had done and what I'd become.

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After many years of struggle, isolation, not knowing, being demeaned by fellow veterans and either being misdiagnosed or not taken seriously 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 (DSM), 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 our conditions 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 - or, better, we hoped -  that we would no longer be ignored or misdiagnosed, and that, now that the psychiatric community understood what we were up against, a cure would 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 would 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 referred to, respectively, as "soldier's heart" during the Civil War," "shell shock" during World War I, and "battle fatigue," and "combat exhaustion" during World War II. Most recently, the designation has lost its poetics, been stripped of its reference to war and battle and become rather clinical. People who are psychologically, emotionally and morally wounded as a result of their combat experience are instead given a diagnosis of PTSD. PTSD, according to the National Institute of Mental Health (NIMH), 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 30 to 35 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 her new book, a recent and important contribution to the literature of war and healing, clinical psychologist and Harvard Kennedy School fellow Caplan  denies that military members' and veterans' "disturbed and lasting emotional response" to war is mental illness. Rather, she favors a position similar to that of Viktor Frankl, who writes in "Man's Search for Meaning" that, "An abnormal reaction to an abnormal situation is normal behavior." Caplan's concern is that to pathologize these "normal" responses "as a mental illness called Post Traumatic Stress Disorder (PTSD) rather than recognizing them as a common ordinary, understandable, human response to war's horrors," is not only inaccurate, but detrimental to veterans' 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, 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 nonjudgmentally to their stories and their experiences. To prepare civilians for an encounter with a vet, Caplan spends the sixth chapter 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 40 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 (EMDR) and cognitive behavioral therapy, to name just a few - yet, vets continue to suffer depression, anxiety, guilt, alienation, and a host of other problems, and they still exhibit high rates of suicide, alcoholism, drug addiction, homelessness and violent crime. Tragically, as soldiers experience the horror and cruelty of war, and especially of urban, counterinsurgency war, the moral gravity of their actions - displacing civilians, torturing, injuring, and killing other human beings - becomes apparent, they may suffer the consequences of acting in violation of their moral identities the moral foundations by which we structure our lives. That is, soldiers suffer not only the effects of trauma, but also moral injuries - that is, 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 - that is, whether we act 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 of recruits' moral foundations experienced during basic training, 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, a combination of the awareness of having transgressed 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 have required returning warriors to undergo elaborate atonement and purification rituals - for example, quarantine, penances, and so on.[2] These "therapies" provided the means and the opportunity to cope with the moral enormity of their actions in war. Tragically, however, the moral injuries of modern warriors 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 - that is, "autonomous man" ought feel no guilt "nor bite of conscience" for his actions.[4] Focusing instead on stress and trauma, most moral symptoms presented by returning soldiers are either not taken seriously or are assimilated under the diagnostic umbrella of PTSD. 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," or 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 doesn't respond 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.

As may be expected, the prevalence of moral injuries suffered by those who fought in a morally ambiguous war, or in a counter insurgency/guerilla war (such as in Vietnam, Iraq or Afghanistan, where, for example, the distinction between combatant and noncombatant is obscure at best) will be significantly greater and the symptoms more severe. However, all wars yield moral casualties. J. Glenn Gray, a philosopher, writes of his experiences as an intelligence officer during World War II:

My conscience seems to become little by little sooted ... (only) if I can soon get out of this war and back on the soil where the clean earth will wash away these stains! I have also other things on my conscience ... A man named H., accused of being the local Gestapo agent in one small town was an old man of seventy.... I was quite harsh to him and remember threatening him with an investigation when I put him under house arrest.... Day before yesterday word came that he and his wife had committed suicide by taking poison ... The incident affected me strongly and still does. I was directly or indirectly the cause of their deaths.... I hope it will not rest too hard on my conscience, and yet if it does not I shall be disturbed also."[7]

Gray's insights are especially valuable as they illustrate that even the actions and experiences of those involved in a "good" war and who did not directly confront the enemy on the battlefield can precipitate moral injury.

Consequently, those military theorists who have argued that debilitating remorse, guilt, shame, and so on may be avoided by "educating" (or, rather, convincing) soldiers about the justness and necessity of war and the "appropriateness" of their combat behavior[8] could benefit from Gray's observations.

To correctly identify and adequately treat the "combat related PEM injuries" suffered by our servicemen and -women in war, we must appreciate the relevancy of moral values and norms to defining ourselves as persons, structuring our world and rendering comprehensible our relationship to it and to other human beings. We must understand that these values and norms provide the parameters of our beings -  what I term our "moral identity." Most importantly, we must recognize that combat behavior often violates our moral identity and negatively impacts our self-esteem, self-image and integrity, causing debilitating remorse, guilt, shame, disorientation and alienation from the remainder of the moral community: this is moral injury.

Acknowledging the existence of moral casualties in war demonstrates that the clinical model - pathologizing a veteran's readjustment difficulties as mental illness - is inadequate and requires further evaluation. On the positive side, it enhances our understanding of the war experience and its devastating effects, expands our area of concern beyond trauma and PTSD, and allows us to more adequately meet the needs of our returning servicemen and -women.

The Normal Response Mode

Though Caplan's concerns regarding the pathologizing of the invisible wounds of war are well founded, her "normal response" model, I fear, may exacerbate the plight of veterans still further. First, to characterize veterans' "disturbed and lasting emotional response" as normal may be misunderstood and/or exploited by the uninitiated and, more importantly, by those concerned more with budgetary constraints than with the well-being of veterans. If, (a) veteran difficulties are merely clusters of "normal" personality and behavioral responses to battlefield conditions (clearly an abnormal situation), and, (b) the traditional clinical psychiatric methods utilized by the VA are costly and ineffective, even detrimental to healing, and, (c) if veteran needs can better be met by volunteer, sympathetic, civilian listeners, I fear that Caplan's program, though certainly well-intended, will lead to cuts in VA funding and other critical veteran programs. Further, I believe, it diminishes an appreciation for and understanding of the scope and seriousness of the invisible wounds of war - raising the question, during this critical economic crisis and with waning support for the wars (and, subsequently, the warrior), as to why we need to continue to spend billions of scarce resources compensating veterans for behavior that is "normal." Finally, and perhaps most importantly, from the veteran's perspective, she understands that her life has changed dramatically since returning from theater. She realizes that she doesn't fit in any longer, feels anger, shame, frustration, is alienated and alone. So, while a veteran may prefer not to think of herself as mentally ill, she certainly understands that something is not right, that  her  feelings and behaviors are not "normal" - that is, as they were before.

In regards to the efficacy of Caplan's Listen to a Vet program, here again I would offer some personal experiences to corroborate my point. It is clear that many veterans choose, for any number of reasons, not to discuss their experiences in war, especially with those who were not there. Others, however, feel obligated to do so. Together with many other members of Veterans For Peace, for example, I have spent many years talking to students, church groups, community organizations - basically, to anyone who would listen - about my personal experiences in war, and, in so doing, about war's nature, reality and consequences. I do so in order to educate and enlighten, believing, at least initially, that war was a deficiency of information, understanding, discernment and vision, and that those who make war, or support war, or just ignore war, do so because they just don't understand its realities.

But with age, experience and study, I have realized that war is not a deficiency at all, but an excess, of greed, ambition, intolerance and lust for power. And we, the warriors, are its instruments, the cannon fodder, expendable commodities in the ruthless pursuit of wealth, power, hegemony and empire.

Despite this realization and the discomfort I feel standing in front of a group of strangers, sharing with them my most secret and distressing feelings, nightmares, and flashbacks, I continue to do it, not because it is curative or purgative or cathartic, but because it is necessary. Many of us who have seen humankind at its worst realize a responsibility to continue to sacrifice, to work for war's eradication. Or perhaps, we do it as retribution, as penance for our participation in the sacrilege of war. I think it is accurate to say that no matter how many times we relate these incidents and experiences to "civilians," or how understanding and sympathetic the listeners may be, it never gets easier. It is always overwhelming, takes a great personal toll and requires many hours to regain our calm and composure.

Caplan is correct, however, in stressing the importance of listening. Should a veteran, for example, especially a family member, feel inclined to discuss her experiences in war, what she is feeling, and so on, by all means, have an open mind and listen. Despite the fact that you may be made uncomfortable by what she has to say, by what she has seen and done while in war, and despite the displeasure you may feel with the realization that as a citizen in a democracy, you must bear some culpability for a war being fought in your name and for the injuries she incurred, have some courage, accept some responsibility and listen to what she has to say. Feel fortunate for this opportunity to learn and that she is willing to share with you such personal and troublesome feelings and experiences. Here I believe Caplan's guidelines for listening will be helpful. But what is crucial to note is that while not listening will send the wrong message to the veteran - that what she did was wrong, unimportant, of no interest to civilians, etcetera, thereby exacerbating her distress and anxiety - listening, even compassionately, understandingly and nonjudgmentally is not in itself the elusive cure that has escaped us these many years.

What I would strongly advise against, therefore, is Caplan's suggestion that civilians seek out veterans and invite, even encourage, them to "share" their experiences, impressions and feelings about war in a well-intentioned attempt to help. What Caplan seems not to appreciate is the extent, severity and complexity of the veteran's injuries. Not only will such an encounter not be beneficial, it may well be harmful, especially to young veterans who have yet to begin the work of "sorting out" the experience and may be coaxed by well-meaning listeners into uncharted and dangerous areas accompanied only by civilians, individuals who have no idea about the nature of war and what they may well encounter while on this journey. It is probable under such conditions that neither the veteran nor the civilian will benefit.

Perhaps this sounds rather cynical, but contra Caplan, my advice to civilians would be to just stay out of the way and do no harm. Realistically, they are ill-equipped to help as - and I know this is cliché - they just weren't there, and, therefore, cannot understand or feel what the veteran is experiencing. Friedrich Nietzsche said it best:

It makes the most telling difference whether a thinker has a personal relationship to his problems and finds in them his destiny, his distress, and his greatest happiness, or an "impersonal" one, meaning he is only able to touch them with the antennae of cold, curious thought. In the latter case nothing will come of it, that much can be promised; for even if great problems should let themselves be grasped by them, they would not allow frogs and weaklings to hold on to them.[9]

We hope that civilians will become educated about the nature and reality of war and its effects on those who experience it, mainly so as not to be misled should some other megalomaniacal leader again attempt to send our children into harm's way. It is not, however, the veterans' responsibility to provide this education, though veterans' voices can be an effective and powerful tool. Nor does their healing require civilian understanding, sympathy or compassion, nor is healing enhanced by civilian appreciation, respect and admiration. An important part of healing is for veterans to confront and then to work through the enormity of the experience of war, the trauma, and the moral realization that they have participated in an enterprise whose only purpose is to kill and mutilate other human beings for a cause that is, at best, legally and morally questionable and ambiguous.

On the road to understanding and to healing, when a veteran has finally put aside the mythology of war's glory and nobility, she cannot help but see war for what it truly is: brutality, cruelty and a violation of all that she, and most of society, holds as sacred and right. So, appreciating and thanking a veteran for her "service," calling her a hero, is counterproductive, as it creates a distraction from the difficult task of confronting the moral enormity of the enterprise of war. That is, it provides a sanctuary of sorts, the mythology to which she may escape when the healing journey gets tough and threatening - and it will - as it is much preferable and comfortable to think oneself a hero, flawed though we may be, than a murderer and a dupe. Besides, all such gestures of respect and appreciation are, in reality, a charade, insincere, pseudopatriotic talk intended to hype sales at the mall and to entice other naive young people to believe war is glorious and heroic, luring them into military service to become the tools and cannon fodder of future wars for profit and power.

Unfortunately, healing and coming home are difficult, complex and perilous journeys of introspection and understanding. So, while it is important that veterans not be ostracized, shunned or ignored should they want to talk, if healing is to occur, it must be with the help of others who have shared the experience, who know the horror firsthand, and not through telling war stories to well-intentioned but voyeuristic civilians.

When a warrior fights not for himself, but for his brothers, when his most passionately sought goal is neither glory nor his own life's preservation, but to spend his substance for them, then his heart truly has achieved contempt for death, and with that he transcends himself and his actions touch the sublime. This is why the true warrior cannot speak of battle save to his brothers who have been there with him. The truth is too holy, too sacred, for words.[10]

I would add: "too horrible." Though I may not share the Spartan aesthetic of war entirely, their mythology does clearly express the very real phenomenon of the soldiers' bond, or "brotherhood of the warrior." Here, I think professionals have a place in sorting this out, perhaps as therapists proficient at staying out of the way and steering the veteran in a direction of healing, and as ethicists who can help to understand and gain a perspective on morality and moral integrity.

Combat-Related Psychological, Emotional, and Moral (PEM) Injuries

The intent of all combat action is to neutralize the enemies' ability to wage war.  The primary means of accomplishing this end in war-fighting is by creating enemy casualties, by rendering the enemy incapable of continuing the hostilities. This  includes, of course, not only killing and physically injuring enemy combatants, but psychologically and emotionally incapacitating them, as well. Consider, for example, the endless artillery bombardment experienced by soldiers fighting in the trenches of the Western Front during World War I. As a consequence of these bombardments, not only were many individuals killed and physically wounded, but many more suffered PEM injuries (then termed shell shock).

Language, how we characterize the human cost of war, its effects on the warrior, is critical both to our understanding of the institution of war and to veteran healing. I doubt, for example, that we would describe a broken tibia sustained during the bombardment as a "normal response" to being hit by shrapnel. Nor would we deem it a physical illness. Rather, we recognize it as a combat injury, a war wound. Similarly, it is just as inaccurate and disingenuous to characterize a broken mind or damaged spirit, whether it is called shell shock, battle fatigue, combat exhaustion or PTSD, as a "normal response" to battlefield conditions or as mental illness. Since PEM injuries are the direct consequence of war-fighting, they are as much combat injuries as a shrapnel-broken tibia. To say otherwise betrays either an effort to disenfranchise PEM-injured veterans or an ignorance of the nature and severity of such injuries and the effects of combat action on the individual.

Though the military has given lip service to the prevalence, severity and debilitating effects of PEM injuries and the importance of treating and screening for their occurrence, given the military's culture of physical and mental toughness, these invisible injuries of war are rarely taken seriously, are ignored completely or are stigmatized as mental illness. Further, military mental health professionals understand implicitly if not explicitly, that their function is to "cure" the soldier quickly, or, more likely, to mask his symptoms with medication and return him to the fighting. An important first step for the military in taking PEM injuries seriously, in eliminating the social stigma attached to seeking treatment, in recognizing such injuries not as a source of weakness, embarrassment or shame, but of courage, honor and sacrifice, would be to recognize the combat-related PEM- injured soldiers as combat-wounded and therefore eligible to be awarded the Purple Heart medal. Tragically, until then, many soldiers and veterans will avoid seeking treatment for their injuries, and for those who do, adequate treatment, and the healing it would help bring about, will not be forthcoming.

Some Further Suggestions for Healing

As trauma certainly remains a critical aspect of the war experience, an encompassing and holistic approach to treating the full spectrum of combat- related PEM injuries may well include traditional and nontraditional clinical intervention for traumatic stress.

As late adolescents and young adults were prepared and programmed for war through a sophisticated indoctrination process - boot camp, basic training - so also, returning warriors must be "de-programmed," that is, prepared to reintegrate into a nonmartial environment. Consequently, veterans require re-education to replace warrior values and behaviors with values appropriate to the society into which they are to reintegrate. This process is intended to shore up their moral identities and verify that this period of horror - their time on the battlefield - was a moral aberration, and that their doubts and questions regarding war and the warrior mythology were well-founded.

Once they have realized the moral uniqueness of the battlefield, veterans should be guided to evaluate and assess, realistically and honestly, their personal responsibility for their actions during war. That is, they must take into account that war's cruelty and brutality distorts character and undermines ethical foundations and moral integrity. Further, they must be prepared to grasp, intellectually and emotionally, the impact such experiences have upon one's perception of correct behavior - war does present a survival situation in which self-preservation and the preservation of comrades' lives becomes a primary motivation. In so doing, veterans may realize that their behavior in combat, though not justifiable, may be understandable, perhaps even excusable, and their culpability mitigated by the fact that those who determined policy, declared the war, issued the orders and allowed the war to occur unchallenged must share responsibility for the inevitable horror of war.

After all is said and done, a veteran may determine that guilt and shame is appropriate given his actions on the battlefield. In such situations, (self-) forgiveness and/or absolution for his moral transgressions may be necessary, whether through religious ritual (confession, sweat lodge, etcetera) or through acts of atonement (community service, or, perhaps, speaking to students, civic organizations and other groups about the nature and reality of war). What is crucial to healing is that guilt not remain "static." While the past can never be undone, nor the dead be made to live again, this "giving back" may allow the veteran, if not to assuage his guilt, at least to have some sort of life around it. It is hoped that such acts of atonement will restore the veteran's sense of integrity - his moral cohesion - thereby raising his self-esteem.

Further, re-establishing a moral identity will restore intelligibility to the veteran's world, his relationship to it and to other human beings, thereby ending his alienation and isolation from the remainder of the moral community.

Some Final Thoughts

However we veterans process the experience, what becomes apparent is that war can never be forgotten or put behind us. We who have experienced its horror can never be made whole again. The best that can be hoped for, I believe, is to find a place for it in our being. This is a perilous journey, a difficult and complex process which, unfortunately, goes well beyond the telling of war stories or listening sessions with understanding, sympathetic and  nonjudgmental civilians.

There are ways, however, that civilians can help. If you know a PEM-injured veteran, suggest that she talk with other vets or with those who truly understand the experience in a group therapeutic environment.

Second, war is violence against human beings: self and others. To help veterans heal and others from becoming victimized, stop the violence, stop the wars.

Third, change the environment in which potential "enemies" are dehumanized and objectified, in which our children are indoctrinated into a culture of violence and hatred and desensitized to the pain and suffering of potential victims.

Fourth, demand that the Constitution, the law of the land, be restored and adhered to, and that only Congress have the ability to declare war or commit troops to combat.

Fifth, demand an end to gunboat diplomacy, and demand that the use of violence and war be a last resort in the event of a real, immediate and serious threat to our national security only.

Sixth, bring the troops home now and ensure that all the necessary resources are made available to assist them to recover from their injuries.

Finally, end the influence of the war profiteers, the robber barons and the military-Congressional-industrial complex that profit from war, from the lives and blood of our children.

1. See my  “The Moral Casualties of War: Understanding the Experience,” in The International Journal  of Applied Philosophy, vol. 13:1, Spring 1999, p.81-92.

2.  For an interesting and detailed discussion of this subject, see Verkamp, Bernard J., The Moral Treatment of Returning Warriors in Early Medieval and Modern Times, (Scranton: University of Scranton Press, 1993).

3.  A few notable exceptions include Robert Jay Lifton, Home From the War: Vietnam Veterans, Neither Victims nor Executioners, (New York, Basic Books), 1973; Veterans Administration Psychiatrist and author Jonathan Shay, Achilles in Vietnam, (New York: Simon & Schuster), 1994; and Odysseus in America, (New York: Scribner), 2002; Ed Tick, Soldier’s Heart Close-Up Today with PTSD in Vietnam Veterans, Praeger (July 30, 2007).

4.Kaufman, Walter, Without Guilt and Justice, (New York: Dell, 1973), pp. 114, 117, 125, 132-133.

5.  Deresponsibilization attempts a "cure" by convincing the patient of the "naturalness" of his behavior under the conditions of war. Stephen Howard explains.
Under the overwhelming threat of annihilation, our priorities regress to the survival state; all higher priorities, all ethical and moral considerations lose relevance, and only the survival of the individual and the immediate group retain significance.

6.  Lifton, Robert J., Home from the War: Vietnam Veterans, Neither Victims nor Executioners, pps. 166-167.

7.  J. Glenn Gray, The Warriors: Reflections on Men in Battle, pp. 175-6.

8. Kilner, Peter G., "Military Leaders Obligation to Justify Killing in War," Military Review, vol. 72, no. 2, Mar-Apr 2004.

9. Friedrich Nietzche, The Gay Science, Bernard Williams, ed., Cambridge University  Press, 2001, p. 202

10. Steven Pressfield, The Gates of Fire, Bantham Books, 1998, p.379

Camillo Mac Bica

Camillo "Mac" Bica, PhD, is a professor of philosophy at the School of Visual Arts in New York City. He is a former Marine Corps officer, Vietnam veteran, longtime activist for peace and social justice, and the coordinator of the Long Island Chapter of Veterans for Peace.

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The Invisible Wounds of War

Monday, 24 October 2011 08:28 By Camillo Mac Bica, Truthout | Op-Ed

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 on 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, for example, 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 combat 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. Although it is a personal story, I am confident it is not unlike the stories of many others who shared the experience.

The Warrior's Perspective: War's Aftermath

I remember thinking amidst the insanity of the Vietnam War, "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 crybaby and a loser, for lacking dedication and effort, for disgracing the "uniform," ourselves and the country for contributing to what was widely regarded as America's first lost 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 after that sadness was replaced 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 (VA). Almost immediately, I was assailed by VA clinicians who "diagnosed" my inability to cope, alienation, nightmares, etcetera 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 and testing and the ad hominem attacks, however, was any 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 25, my life was over. Was I crazy, a baby killer, a crybaby, a coward? Perhaps I was all of these. Needless to say, I wasn't very pleased 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 going 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 an acceptance, of what I had done and what I'd become.

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After many years of struggle, isolation, not knowing, being demeaned by fellow veterans and either being misdiagnosed or not taken seriously 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 (DSM), 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 our conditions 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 - or, better, we hoped -  that we would no longer be ignored or misdiagnosed, and that, now that the psychiatric community understood what we were up against, a cure would 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 would 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 referred to, respectively, as "soldier's heart" during the Civil War," "shell shock" during World War I, and "battle fatigue," and "combat exhaustion" during World War II. Most recently, the designation has lost its poetics, been stripped of its reference to war and battle and become rather clinical. People who are psychologically, emotionally and morally wounded as a result of their combat experience are instead given a diagnosis of PTSD. PTSD, according to the National Institute of Mental Health (NIMH), 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 30 to 35 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 her new book, a recent and important contribution to the literature of war and healing, clinical psychologist and Harvard Kennedy School fellow Caplan  denies that military members' and veterans' "disturbed and lasting emotional response" to war is mental illness. Rather, she favors a position similar to that of Viktor Frankl, who writes in "Man's Search for Meaning" that, "An abnormal reaction to an abnormal situation is normal behavior." Caplan's concern is that to pathologize these "normal" responses "as a mental illness called Post Traumatic Stress Disorder (PTSD) rather than recognizing them as a common ordinary, understandable, human response to war's horrors," is not only inaccurate, but detrimental to veterans' 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, 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 nonjudgmentally to their stories and their experiences. To prepare civilians for an encounter with a vet, Caplan spends the sixth chapter 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 40 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 (EMDR) and cognitive behavioral therapy, to name just a few - yet, vets continue to suffer depression, anxiety, guilt, alienation, and a host of other problems, and they still exhibit high rates of suicide, alcoholism, drug addiction, homelessness and violent crime. Tragically, as soldiers experience the horror and cruelty of war, and especially of urban, counterinsurgency war, the moral gravity of their actions - displacing civilians, torturing, injuring, and killing other human beings - becomes apparent, they may suffer the consequences of acting in violation of their moral identities the moral foundations by which we structure our lives. That is, soldiers suffer not only the effects of trauma, but also moral injuries - that is, 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 - that is, whether we act 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 of recruits' moral foundations experienced during basic training, 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, a combination of the awareness of having transgressed 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 have required returning warriors to undergo elaborate atonement and purification rituals - for example, quarantine, penances, and so on.[2] These "therapies" provided the means and the opportunity to cope with the moral enormity of their actions in war. Tragically, however, the moral injuries of modern warriors 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 - that is, "autonomous man" ought feel no guilt "nor bite of conscience" for his actions.[4] Focusing instead on stress and trauma, most moral symptoms presented by returning soldiers are either not taken seriously or are assimilated under the diagnostic umbrella of PTSD. 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," or 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 doesn't respond 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.

As may be expected, the prevalence of moral injuries suffered by those who fought in a morally ambiguous war, or in a counter insurgency/guerilla war (such as in Vietnam, Iraq or Afghanistan, where, for example, the distinction between combatant and noncombatant is obscure at best) will be significantly greater and the symptoms more severe. However, all wars yield moral casualties. J. Glenn Gray, a philosopher, writes of his experiences as an intelligence officer during World War II:

My conscience seems to become little by little sooted ... (only) if I can soon get out of this war and back on the soil where the clean earth will wash away these stains! I have also other things on my conscience ... A man named H., accused of being the local Gestapo agent in one small town was an old man of seventy.... I was quite harsh to him and remember threatening him with an investigation when I put him under house arrest.... Day before yesterday word came that he and his wife had committed suicide by taking poison ... The incident affected me strongly and still does. I was directly or indirectly the cause of their deaths.... I hope it will not rest too hard on my conscience, and yet if it does not I shall be disturbed also."[7]

Gray's insights are especially valuable as they illustrate that even the actions and experiences of those involved in a "good" war and who did not directly confront the enemy on the battlefield can precipitate moral injury.

Consequently, those military theorists who have argued that debilitating remorse, guilt, shame, and so on may be avoided by "educating" (or, rather, convincing) soldiers about the justness and necessity of war and the "appropriateness" of their combat behavior[8] could benefit from Gray's observations.

To correctly identify and adequately treat the "combat related PEM injuries" suffered by our servicemen and -women in war, we must appreciate the relevancy of moral values and norms to defining ourselves as persons, structuring our world and rendering comprehensible our relationship to it and to other human beings. We must understand that these values and norms provide the parameters of our beings -  what I term our "moral identity." Most importantly, we must recognize that combat behavior often violates our moral identity and negatively impacts our self-esteem, self-image and integrity, causing debilitating remorse, guilt, shame, disorientation and alienation from the remainder of the moral community: this is moral injury.

Acknowledging the existence of moral casualties in war demonstrates that the clinical model - pathologizing a veteran's readjustment difficulties as mental illness - is inadequate and requires further evaluation. On the positive side, it enhances our understanding of the war experience and its devastating effects, expands our area of concern beyond trauma and PTSD, and allows us to more adequately meet the needs of our returning servicemen and -women.

The Normal Response Mode

Though Caplan's concerns regarding the pathologizing of the invisible wounds of war are well founded, her "normal response" model, I fear, may exacerbate the plight of veterans still further. First, to characterize veterans' "disturbed and lasting emotional response" as normal may be misunderstood and/or exploited by the uninitiated and, more importantly, by those concerned more with budgetary constraints than with the well-being of veterans. If, (a) veteran difficulties are merely clusters of "normal" personality and behavioral responses to battlefield conditions (clearly an abnormal situation), and, (b) the traditional clinical psychiatric methods utilized by the VA are costly and ineffective, even detrimental to healing, and, (c) if veteran needs can better be met by volunteer, sympathetic, civilian listeners, I fear that Caplan's program, though certainly well-intended, will lead to cuts in VA funding and other critical veteran programs. Further, I believe, it diminishes an appreciation for and understanding of the scope and seriousness of the invisible wounds of war - raising the question, during this critical economic crisis and with waning support for the wars (and, subsequently, the warrior), as to why we need to continue to spend billions of scarce resources compensating veterans for behavior that is "normal." Finally, and perhaps most importantly, from the veteran's perspective, she understands that her life has changed dramatically since returning from theater. She realizes that she doesn't fit in any longer, feels anger, shame, frustration, is alienated and alone. So, while a veteran may prefer not to think of herself as mentally ill, she certainly understands that something is not right, that  her  feelings and behaviors are not "normal" - that is, as they were before.

In regards to the efficacy of Caplan's Listen to a Vet program, here again I would offer some personal experiences to corroborate my point. It is clear that many veterans choose, for any number of reasons, not to discuss their experiences in war, especially with those who were not there. Others, however, feel obligated to do so. Together with many other members of Veterans For Peace, for example, I have spent many years talking to students, church groups, community organizations - basically, to anyone who would listen - about my personal experiences in war, and, in so doing, about war's nature, reality and consequences. I do so in order to educate and enlighten, believing, at least initially, that war was a deficiency of information, understanding, discernment and vision, and that those who make war, or support war, or just ignore war, do so because they just don't understand its realities.

But with age, experience and study, I have realized that war is not a deficiency at all, but an excess, of greed, ambition, intolerance and lust for power. And we, the warriors, are its instruments, the cannon fodder, expendable commodities in the ruthless pursuit of wealth, power, hegemony and empire.

Despite this realization and the discomfort I feel standing in front of a group of strangers, sharing with them my most secret and distressing feelings, nightmares, and flashbacks, I continue to do it, not because it is curative or purgative or cathartic, but because it is necessary. Many of us who have seen humankind at its worst realize a responsibility to continue to sacrifice, to work for war's eradication. Or perhaps, we do it as retribution, as penance for our participation in the sacrilege of war. I think it is accurate to say that no matter how many times we relate these incidents and experiences to "civilians," or how understanding and sympathetic the listeners may be, it never gets easier. It is always overwhelming, takes a great personal toll and requires many hours to regain our calm and composure.

Caplan is correct, however, in stressing the importance of listening. Should a veteran, for example, especially a family member, feel inclined to discuss her experiences in war, what she is feeling, and so on, by all means, have an open mind and listen. Despite the fact that you may be made uncomfortable by what she has to say, by what she has seen and done while in war, and despite the displeasure you may feel with the realization that as a citizen in a democracy, you must bear some culpability for a war being fought in your name and for the injuries she incurred, have some courage, accept some responsibility and listen to what she has to say. Feel fortunate for this opportunity to learn and that she is willing to share with you such personal and troublesome feelings and experiences. Here I believe Caplan's guidelines for listening will be helpful. But what is crucial to note is that while not listening will send the wrong message to the veteran - that what she did was wrong, unimportant, of no interest to civilians, etcetera, thereby exacerbating her distress and anxiety - listening, even compassionately, understandingly and nonjudgmentally is not in itself the elusive cure that has escaped us these many years.

What I would strongly advise against, therefore, is Caplan's suggestion that civilians seek out veterans and invite, even encourage, them to "share" their experiences, impressions and feelings about war in a well-intentioned attempt to help. What Caplan seems not to appreciate is the extent, severity and complexity of the veteran's injuries. Not only will such an encounter not be beneficial, it may well be harmful, especially to young veterans who have yet to begin the work of "sorting out" the experience and may be coaxed by well-meaning listeners into uncharted and dangerous areas accompanied only by civilians, individuals who have no idea about the nature of war and what they may well encounter while on this journey. It is probable under such conditions that neither the veteran nor the civilian will benefit.

Perhaps this sounds rather cynical, but contra Caplan, my advice to civilians would be to just stay out of the way and do no harm. Realistically, they are ill-equipped to help as - and I know this is cliché - they just weren't there, and, therefore, cannot understand or feel what the veteran is experiencing. Friedrich Nietzsche said it best:

It makes the most telling difference whether a thinker has a personal relationship to his problems and finds in them his destiny, his distress, and his greatest happiness, or an "impersonal" one, meaning he is only able to touch them with the antennae of cold, curious thought. In the latter case nothing will come of it, that much can be promised; for even if great problems should let themselves be grasped by them, they would not allow frogs and weaklings to hold on to them.[9]

We hope that civilians will become educated about the nature and reality of war and its effects on those who experience it, mainly so as not to be misled should some other megalomaniacal leader again attempt to send our children into harm's way. It is not, however, the veterans' responsibility to provide this education, though veterans' voices can be an effective and powerful tool. Nor does their healing require civilian understanding, sympathy or compassion, nor is healing enhanced by civilian appreciation, respect and admiration. An important part of healing is for veterans to confront and then to work through the enormity of the experience of war, the trauma, and the moral realization that they have participated in an enterprise whose only purpose is to kill and mutilate other human beings for a cause that is, at best, legally and morally questionable and ambiguous.

On the road to understanding and to healing, when a veteran has finally put aside the mythology of war's glory and nobility, she cannot help but see war for what it truly is: brutality, cruelty and a violation of all that she, and most of society, holds as sacred and right. So, appreciating and thanking a veteran for her "service," calling her a hero, is counterproductive, as it creates a distraction from the difficult task of confronting the moral enormity of the enterprise of war. That is, it provides a sanctuary of sorts, the mythology to which she may escape when the healing journey gets tough and threatening - and it will - as it is much preferable and comfortable to think oneself a hero, flawed though we may be, than a murderer and a dupe. Besides, all such gestures of respect and appreciation are, in reality, a charade, insincere, pseudopatriotic talk intended to hype sales at the mall and to entice other naive young people to believe war is glorious and heroic, luring them into military service to become the tools and cannon fodder of future wars for profit and power.

Unfortunately, healing and coming home are difficult, complex and perilous journeys of introspection and understanding. So, while it is important that veterans not be ostracized, shunned or ignored should they want to talk, if healing is to occur, it must be with the help of others who have shared the experience, who know the horror firsthand, and not through telling war stories to well-intentioned but voyeuristic civilians.

When a warrior fights not for himself, but for his brothers, when his most passionately sought goal is neither glory nor his own life's preservation, but to spend his substance for them, then his heart truly has achieved contempt for death, and with that he transcends himself and his actions touch the sublime. This is why the true warrior cannot speak of battle save to his brothers who have been there with him. The truth is too holy, too sacred, for words.[10]

I would add: "too horrible." Though I may not share the Spartan aesthetic of war entirely, their mythology does clearly express the very real phenomenon of the soldiers' bond, or "brotherhood of the warrior." Here, I think professionals have a place in sorting this out, perhaps as therapists proficient at staying out of the way and steering the veteran in a direction of healing, and as ethicists who can help to understand and gain a perspective on morality and moral integrity.

Combat-Related Psychological, Emotional, and Moral (PEM) Injuries

The intent of all combat action is to neutralize the enemies' ability to wage war.  The primary means of accomplishing this end in war-fighting is by creating enemy casualties, by rendering the enemy incapable of continuing the hostilities. This  includes, of course, not only killing and physically injuring enemy combatants, but psychologically and emotionally incapacitating them, as well. Consider, for example, the endless artillery bombardment experienced by soldiers fighting in the trenches of the Western Front during World War I. As a consequence of these bombardments, not only were many individuals killed and physically wounded, but many more suffered PEM injuries (then termed shell shock).

Language, how we characterize the human cost of war, its effects on the warrior, is critical both to our understanding of the institution of war and to veteran healing. I doubt, for example, that we would describe a broken tibia sustained during the bombardment as a "normal response" to being hit by shrapnel. Nor would we deem it a physical illness. Rather, we recognize it as a combat injury, a war wound. Similarly, it is just as inaccurate and disingenuous to characterize a broken mind or damaged spirit, whether it is called shell shock, battle fatigue, combat exhaustion or PTSD, as a "normal response" to battlefield conditions or as mental illness. Since PEM injuries are the direct consequence of war-fighting, they are as much combat injuries as a shrapnel-broken tibia. To say otherwise betrays either an effort to disenfranchise PEM-injured veterans or an ignorance of the nature and severity of such injuries and the effects of combat action on the individual.

Though the military has given lip service to the prevalence, severity and debilitating effects of PEM injuries and the importance of treating and screening for their occurrence, given the military's culture of physical and mental toughness, these invisible injuries of war are rarely taken seriously, are ignored completely or are stigmatized as mental illness. Further, military mental health professionals understand implicitly if not explicitly, that their function is to "cure" the soldier quickly, or, more likely, to mask his symptoms with medication and return him to the fighting. An important first step for the military in taking PEM injuries seriously, in eliminating the social stigma attached to seeking treatment, in recognizing such injuries not as a source of weakness, embarrassment or shame, but of courage, honor and sacrifice, would be to recognize the combat-related PEM- injured soldiers as combat-wounded and therefore eligible to be awarded the Purple Heart medal. Tragically, until then, many soldiers and veterans will avoid seeking treatment for their injuries, and for those who do, adequate treatment, and the healing it would help bring about, will not be forthcoming.

Some Further Suggestions for Healing

As trauma certainly remains a critical aspect of the war experience, an encompassing and holistic approach to treating the full spectrum of combat- related PEM injuries may well include traditional and nontraditional clinical intervention for traumatic stress.

As late adolescents and young adults were prepared and programmed for war through a sophisticated indoctrination process - boot camp, basic training - so also, returning warriors must be "de-programmed," that is, prepared to reintegrate into a nonmartial environment. Consequently, veterans require re-education to replace warrior values and behaviors with values appropriate to the society into which they are to reintegrate. This process is intended to shore up their moral identities and verify that this period of horror - their time on the battlefield - was a moral aberration, and that their doubts and questions regarding war and the warrior mythology were well-founded.

Once they have realized the moral uniqueness of the battlefield, veterans should be guided to evaluate and assess, realistically and honestly, their personal responsibility for their actions during war. That is, they must take into account that war's cruelty and brutality distorts character and undermines ethical foundations and moral integrity. Further, they must be prepared to grasp, intellectually and emotionally, the impact such experiences have upon one's perception of correct behavior - war does present a survival situation in which self-preservation and the preservation of comrades' lives becomes a primary motivation. In so doing, veterans may realize that their behavior in combat, though not justifiable, may be understandable, perhaps even excusable, and their culpability mitigated by the fact that those who determined policy, declared the war, issued the orders and allowed the war to occur unchallenged must share responsibility for the inevitable horror of war.

After all is said and done, a veteran may determine that guilt and shame is appropriate given his actions on the battlefield. In such situations, (self-) forgiveness and/or absolution for his moral transgressions may be necessary, whether through religious ritual (confession, sweat lodge, etcetera) or through acts of atonement (community service, or, perhaps, speaking to students, civic organizations and other groups about the nature and reality of war). What is crucial to healing is that guilt not remain "static." While the past can never be undone, nor the dead be made to live again, this "giving back" may allow the veteran, if not to assuage his guilt, at least to have some sort of life around it. It is hoped that such acts of atonement will restore the veteran's sense of integrity - his moral cohesion - thereby raising his self-esteem.

Further, re-establishing a moral identity will restore intelligibility to the veteran's world, his relationship to it and to other human beings, thereby ending his alienation and isolation from the remainder of the moral community.

Some Final Thoughts

However we veterans process the experience, what becomes apparent is that war can never be forgotten or put behind us. We who have experienced its horror can never be made whole again. The best that can be hoped for, I believe, is to find a place for it in our being. This is a perilous journey, a difficult and complex process which, unfortunately, goes well beyond the telling of war stories or listening sessions with understanding, sympathetic and  nonjudgmental civilians.

There are ways, however, that civilians can help. If you know a PEM-injured veteran, suggest that she talk with other vets or with those who truly understand the experience in a group therapeutic environment.

Second, war is violence against human beings: self and others. To help veterans heal and others from becoming victimized, stop the violence, stop the wars.

Third, change the environment in which potential "enemies" are dehumanized and objectified, in which our children are indoctrinated into a culture of violence and hatred and desensitized to the pain and suffering of potential victims.

Fourth, demand that the Constitution, the law of the land, be restored and adhered to, and that only Congress have the ability to declare war or commit troops to combat.

Fifth, demand an end to gunboat diplomacy, and demand that the use of violence and war be a last resort in the event of a real, immediate and serious threat to our national security only.

Sixth, bring the troops home now and ensure that all the necessary resources are made available to assist them to recover from their injuries.

Finally, end the influence of the war profiteers, the robber barons and the military-Congressional-industrial complex that profit from war, from the lives and blood of our children.

1. See my  “The Moral Casualties of War: Understanding the Experience,” in The International Journal  of Applied Philosophy, vol. 13:1, Spring 1999, p.81-92.

2.  For an interesting and detailed discussion of this subject, see Verkamp, Bernard J., The Moral Treatment of Returning Warriors in Early Medieval and Modern Times, (Scranton: University of Scranton Press, 1993).

3.  A few notable exceptions include Robert Jay Lifton, Home From the War: Vietnam Veterans, Neither Victims nor Executioners, (New York, Basic Books), 1973; Veterans Administration Psychiatrist and author Jonathan Shay, Achilles in Vietnam, (New York: Simon & Schuster), 1994; and Odysseus in America, (New York: Scribner), 2002; Ed Tick, Soldier’s Heart Close-Up Today with PTSD in Vietnam Veterans, Praeger (July 30, 2007).

4.Kaufman, Walter, Without Guilt and Justice, (New York: Dell, 1973), pp. 114, 117, 125, 132-133.

5.  Deresponsibilization attempts a "cure" by convincing the patient of the "naturalness" of his behavior under the conditions of war. Stephen Howard explains.
Under the overwhelming threat of annihilation, our priorities regress to the survival state; all higher priorities, all ethical and moral considerations lose relevance, and only the survival of the individual and the immediate group retain significance.

6.  Lifton, Robert J., Home from the War: Vietnam Veterans, Neither Victims nor Executioners, pps. 166-167.

7.  J. Glenn Gray, The Warriors: Reflections on Men in Battle, pp. 175-6.

8. Kilner, Peter G., "Military Leaders Obligation to Justify Killing in War," Military Review, vol. 72, no. 2, Mar-Apr 2004.

9. Friedrich Nietzche, The Gay Science, Bernard Williams, ed., Cambridge University  Press, 2001, p. 202

10. Steven Pressfield, The Gates of Fire, Bantham Books, 1998, p.379

Camillo Mac Bica

Camillo "Mac" Bica, PhD, is a professor of philosophy at the School of Visual Arts in New York City. He is a former Marine Corps officer, Vietnam veteran, longtime activist for peace and social justice, and the coordinator of the Long Island Chapter of Veterans for Peace.

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