A government decides to contribute troops to an international military intervention. On the mission, the deployed soldiers confront difficult circumstances. Casualties mount: among the opponents, among the own troops, and among civilians. Meanwhile, the mission is the subject of debate in parliament and media, which heats up when something happens to draw the legitimacy of the mission into question. How did it happen? Who is responsible? What should they have done differently? Was this mission not doomed from the start? Eventually, these questions are translated into Lessons Learned, to prevent similar failures in the future.
This is one way to describe military intervention and related issues of justice, responsibility and blame. Its bird’s view approach provides a structured and legible overview, allowing a clear understanding of a military mission’s course of events. As such, however, it offers only little insight into the experience of those involved in the mission.
Another way to describe an intervention is as follows. The veteran – still a young man – recounts the difficult circumstances he and his colleagues confronted while on deployment.
Initially he speaks about his deployment and homecoming experience in a matter-of-fact and almost casual manner, yet visibly tenses when discussing disturbing experiences. He has struggled with lingering doubts about situations in which he made choices he did not want to make. Is he responsible for those people’s suffering? This question still haunts him. At the same time, he feels that he did what he did because he had no other option. He often asks himself, what were they doing there in the first place? The government sent them there with limited resources and then abandoned them to their fate. Over there, and back here.
On returning home, he started to work hard and party hard. He became aggressive, at work and at home, driven into a spiral of guilt and anger. At first, however, he did not link any of this to his deployment. Even so, he refused to talk about it because he was afraid of being condemned. Accusations about what they had done wrong over there would slice into him like a knife and infuriate him, because people had no idea of what had happened there. At the same time, the accusations hurt so much because self-reproach kept him up until early in the morning. Still, for a long time he thought he was fine, and that in fact he was the lucky one for not developing problems, up until his haunting thoughts and feelings finally made him collapse. He sought help and eventually received a diagnosis of post-traumatic stress disorder (PTSD). Yet, even if his PTSD-focused therapy helped counter his persistent tension, it could not rid him of his feelings of guilt and anger. His family and friends insisted that nobody was to blame for what had happened, but he kept struggling with the sense that he and others should have acted differently.
In the present study, I adopt this second approach of considering moral dimensions of military practice from below, focusing on the experiences of Dutch veterans deployed to Srebrenica, the former Yugoslavia, and Uruzgan, Afghanistan, and on to what extent and how their experiences were embedded in the wider sociopolitical context of their missions. In doing so, I attempt to better understand how moral challenges at both the micro- and macro-level affect soldiers ‘on the ground’ and potentially generate distress among them.
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Chapter 1 IntroductionPart I Setting the StageMoral Injury: Linking the Moral and the Psychological
Many of the stories I have collected over the past years are about perceived personal failure, betrayal of trust, guilt and anger, and suffering. Put differently, they are about questions of right and wrong, the psychological experience of distress, and the link between them. Both scientific and media discourses of military intervention, however, tend to separate these two topics.
The topic of moral questions surrounding military intervention is usually dealt with in the domains of political ethics and law. These domains discuss when military intervention is justified, what conduct is legitimate, and where responsibility lies in the case of transgression (see e.g. Walzer 1973, 1977, Ely 1993, Ó Tuathail 1999, Ramsey 2002, Evans 2005, Parrish 2007, Cooper and Kohler 2009, Dorn 2011, Wijze 2012, Berkowitz 2013, Orend 2013). While this approach offers normative considerations for military practice, it does not necessarily yield insight into how soldiers struggle with questions of right and wrong and thus develop distress.
At the same time, the topic of soldiers’ distress is predominantly taken up in the medical domain, and conceptualized as post-traumatic stress disorder (Kienzler 2008, Scandlyn and Hautzinger 2014). In most Western countries, the concept has become so well-known that it is often only referred to by its acronym, and many war movies depict typical PTSD symptoms such as jumpiness and vivid flashbacks. Most current models of the disorder define PTSD as the result of exposure to (threatened) violence or injury, and identify fear as the reaction lying at the core of post-traumatic stress (DePrince and Freyd 2002, Litz et al. 2009, Drescher et al. 2011, Difede et al. 2014). Consequently, moral dimensions of trauma generally receive little attention (Shay 1994, Bica 1999, Litz et al. 2009, Drescher et al. 2011).
However, there is considerable evidence indicating that moral challenges encountered during deployment may engender profound suffering. Mental health practitioners working with veterans report that moral conflict is a significant element of many veterans’ struggles (Shay 1994, Drescher et al. 2011), and their observations resonate with academic research on this matter. In a survey conducted among US combat veterans, 10.8% reported engagement in moral transgressions, 25.5% reported transgressions by others, and 25.5% reported feelings of betrayal (Wisco et al. 2017). Another survey showed that 28% of US Iraq and Afghanistan veterans had encountered ‘ethical situations’, in which they ‘did not know how to respond’
(MHAT-V 2008, p. 58). Schut (2015), similarly, found that Dutch soldiers are often confronted by ‘morally critical situations’. Moreover, many studies find that a significant proportion of soldiers faced by such situations develop feelings of shame, guilt and/or anger (see e.g. Litz et al. 2009, Ritov and Barnetz 2014, Currier et al. 2015, Bryan et al. 2016, Frankfurt and Frazier 2016, Jordan et al. 2017, Wisco et al. 2017). Though most of these studies focus on combat soldiers, and particularly on the moral impact of killing, others indicate that negative moral emotions may also arise in other deployment circumstances. A study among Dutch peacekeepers (Rietveld 2009), for instance, found that 25% felt guilty about their deployment experience, of which one third experienced distress due to their feelings of guilt.
The idea that war can be morally disrupting is ancient (see Shay 1994, 2002). However, systematic, comprehensive efforts to conceptualize moral dimensions of deployment-related
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Part I Setting the StageChapter 1 Introduction
distress are relatively recent (Litz et al. 2009, Maguen and Litz 2012, Nash and Litz 2013, Shay 2014). In 2009, psychologist Brett Litz and his colleagues introduced a preliminary, now often-cited conceptual model of ‘moral injury’ (Litz et al. 2009, 2015, Nash and Litz 2013, Nash et al.
2013). The model is intended to capture what current PTSD models fail to sufficiently address:
moral dimensions of trauma. The general idea is that moral injury results from deployment experiences that affect a soldier’s moral foundations and thus cause suffering. Specifically, it is defined as the result of ‘an act of transgression that creates dissonance and conflict because it violates assumptions and beliefs about right and wrong and personal goodness’ (Litz et al. 2009, p. 689, see also Boudreau 2011, Drescher et al. 2011, Shay 2014). Although some symptoms assigned to moral injury overlap with those of PTSD, such as intrusive distressing memories, avoidance behavior and numbing, other symptoms are believed to be specific to moral injury, including demoralization, self-sabotaging behaviors and self-injury (Litz et al. 2009, Maguen and Litz 2012, Frankfurt and Frazier 2016). Also, whereas in current PTSD models feelings of guilt, shame and anger are readily approached as misplaced emotions that need to be corrected, in the concept of moral injury they are understood as possibly appropriate (Litz et al. 2009, Nash and Litz 2013). ‘Moral injury’, in short, addresses the link between moral issues of military intervention and psychological distress.
The concept of moral injury has attracted fast-growing attention in both academic and public discourse. Many studies are currently working on developing workable clinical models for moral injury. These studies seek to validate the concept with empirical evidence (e.g.
Drescher et al. 2011, Maguen and Litz 2012, Vargas et al. 2013), facilitate the measurement and diagnosis of moral injury (Nash et al. 2013, Currier et al. 2015, 2017, Bryan et al. 2016, Koenig et al. 2018) and develop therapies for moral injury (Gray et al. 2012, Steenkamp et al. 2013, Paul et al. 2014, Laifer et al. 2015, Litz et al. 2015, Farnsworth et al. 2017, Griffin et al. 2017, Held et al. 2018). Such research is valuable. In addition to working on the validation, diagnosis and treatment of moral injury, however, it is important to take a step back and work on the concept itself, as it is still in its developmental stages. First, the concept needs empirical and theoretical development regarding the specific mechanisms at play (Maguen and Litz 2012, Frame 2015, Frankfurt and Frazier 2016, Farnsworth et al. 2017). Moreover, as critical attitudes suggest, it may need modification. Though ‘moral injury’ is intended to address the moral aspects that current PTSD models fail to capture, the current concept still focuses on the ‘injury’ while attending too little to the ‘moral’ (Kinghorn 2012, Wilson 2014, Beard 2015, Molendijk et al. 2018). Also, like current PTSD models, it decontextualizes deployment-related trauma away from the people who send soldiers on a mission and welcome them back (MacLeish 2010, Scandlyn and Hautzinger 2014, Molendijk et al. 2018).
In the present study I address these gaps, aiming to advance the concept of moral injury by attending to three related issues. The first issue concerns questions about ‘the moral’
in ‘moral injury’. The current concept describes a person’s moral beliefs as a ‘code’ which may be violated by intruding acts (see e.g. Litz et al. 2009, Ritov and Barnetz 2014, Currier et al. 2015, Bryan et al. 2016, Frankfurt and Frazier 2016, Jordan et al. 2017, Wisco et al. 2017), a conceptualization that can be further developed and refined. As philosophical and social scientific studies teach us, moral beliefs do not constitute a harmonious system but a total of multiple, potentially competing values (e.g. Zigon 2008, Hitlin and Vaisey 2013, Tessman
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Chapter 1 IntroductionPart I Setting the Stage2014). Soldiers internalize both civilian and military values, and as soldiers they are not merely instruments of the state who must adhere to political norms, but always remain moral agents with personal values (e.g. Baarda and Verweij 2006, Molendijk et al. 2018).
In other words, soldiers have multiple moral commitments that may co-exist in tension, and it seems worthwhile to examine whether and how this complexity plays a role in the experience of ‘moral injury’.
The second and third issues concern the role of political practices and public debates in
‘moral injury’. Both issues relate to the fact that soldiers – as civilians, soldiers, instruments of the state and so on – do not live in a social vacuum, but with reference to the political domain and society. The current concept of moral injury ‘keeps the emphasis on the individual soldier and his or her actions and away from the political and military leaders who ordered them into combat and the civilians, willingly or not, who stand behind them’
(Scandlyn and Hautzinger 2014, p. 15). However, political practices and public perceptions clearly have consequences for circumstances on the micro-level. They shape the ways in which soldiers are deployed and how soldiers are perceived and treated when they get back;
they shape and constrain soldiers’ actions on deployment, and co-construct judgments on what soldiers have done or failed to do. Therefore, it is worth examining whether such political practices and public perceptions play a role in experiences of ‘moral injury’, and if so, in what ways.
Research Objectives and Questions
Before being able to translate the above considerations into specific research objectives and questions, I need to outline this study’s approach to the concept of moral injury. To refine and possibly modify this concept requires critical reflection on the concept itself, the phenomena it aims to capture and the relation between both. Therefore, rather than readily accepting the current moral injury concept as established fact, I will carefully observe the distinction between the concept of moral injury and the phenomena this concept seeks to understand – just as one may distinguish, for instance, between the psychiatric concept of
‘major depressive disorder’ and the phenomena of feeling worthless, being unable to gain pleasure from activities, feeling restless and having trouble getting to sleep.
Research on psychological concepts, particularly, is often plagued by reification, that is, by misreading analytical abstractions as ‘things’ existing in objective reality (Hyman 2010, Dehue 2011, Nesse and Stein 2012, Korteling 2014). To avoid confusion and explicitly refrain from reification, I use different terms for concept and phenomena, respectively. I use the term moral injury to refer to the concept of moral injury developed by Litz and colleagues (Litz et al. 2009, 2015, Nash and Litz 2013, Nash et al. 2013). This concept puts forward a particular psychological definition of the moral dimension of deployment-related suffering (a mental wound yet distinct from PTSD), a particular cause (transgression of the own moral code) and particular solutions (including therapy focused on self-forgiveness). The phenomena that this concept aims to capture, I label as moral distress, intended as a nonspecific, open term.
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Part I Setting the StageChapter 1 Introduction
It is not intended as yet another theoretical concept alongside the moral injury concept, but simply as shorthand for ‘moral dimensions of deployment-related hurt or suffering’ for the lack of a shorter term.
Having clarified this, I can formulate the overall objective of this study: to advance the empirical and theoretical understanding of moral, political and societal dimensions of deployment-related moral distress, and in doing so, contribute to the concept of ‘moral injury’ and to practical interventions to address and prevent moral distress. This objective is achieved by examining (potential) moral dimensions of experiences of distress, and the (potential) role of political practices and public perceptions in experiences of moral distress, among Dutchbat and Task Force Uruzgan (TFU) veterans. For this endeavor, I draw on case study-oriented empirical research I conducted involving 40 Dutchbat veterans deployed to Srebrenica, the former Yugoslavia, and 40 Dutch TFU veterans deployed to Uruzgan, Afghanistan. ‘Veterans’ refers to persons who have been on a mission and may or may not still be serving on active duty.
Achieving the objectives involves examining the following research questions:
what do (potential) moral dimensions of distress among veterans involve, what is the (potential) role of political practices and public perceptions in veterans’
experiences of moral distress, and what does this mean for the concept of ‘moral injury’ and for practical interventions to address and prevent moral distress?
Examining these questions in turn involves the following steps (see Figure 5).
Figure 5: Research Framework
The first step is a literature review of relevant existing studies from the fields of psychology, philosophy and social sciences regarding the topics of trauma, morality and sociopolitical aspects of mental suffering. The subsequent step involves a multiple case study among Dutchbat and TFU veterans, answering the following subquestions.
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Chapter 1 IntroductionPart I Setting the StageThe individual level
1. How did Dutchbat and TFU soldiers in general interpret and cope with (potential) moral challenges related to their profession?
2. Did Dutchbat and TFU (ex-)soldiers report distress related to moral challenges, and if so, what did these challenges and experiences of distress entail?
Moral distress in relation to factors at the political level
3. Did political practices surrounding the Dutchbat and TFU missions, including decision-making practices related to the mission design, its framing and practices in the mission’s aftermath, play a role in experiences of moral distress among deployed (ex-)soldiers, and if so, how?
Moral distress in relation to factors at the societal level
4. Did public perceptions of the Dutchbat and TFU missions and of the military in general, as expressed in for instance public debates, play a role in experiences of moral distress among (ex-)soldiers deployed on these missions, and if so, how?
The final step concerns determining the implications of the findings of this multiple case study. In terms of the theoretical implications, this involves answering the question of how the findings correspond with, add to or diverge from the current concept of moral injury, and how they contribute to the development and potential refinement of the concept. Reflecting on the findings involves translating them into practical implications for the question of how to address and decrease moral distress among (ex-)soldiers.
Relevance
This study takes up several critiques and appeals from different disciplines with regard to understanding deployment-related distress. First, it answers recent calls for research on moral aspects of mental health problems among veterans, termed moral injury (e.g. Boudreau 2011, Brock and Lettini 2012, Kinghorn 2012, Nash and Litz 2013, Farnsworth 2014, Meagher 2014, Shay 2014, Frame 2015). Second, it takes up persistent calls to address societal factors involved in war-related suffering, which overspill the boundaries of prevalent trauma models (Kleinman et al. 1997, Summerfield 2001, Withuis 2002, Kienzler 2008, Efraime and Errante 2012, Suarez 2013, Daphna-Tekoah and Harel-Shalev 2017) as well as those of current conceptualizations of moral injury (MacLeish 2010, 2018, Scandlyn and Hautzinger 2014). Third, it responds to appeals to go beyond an understanding of psychological distress in terms of disease, and also appreciate such distress as more or other than pathological (e.g. Kleinman et al. 1997,
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Part I Setting the StageChapter 1 Introduction
Summerfield 2000, Withuis 2002, Das 2007, Kinghorn 2012, Hautzinger and Scandlyn 2013, Daphna-Tekoah and Harel-Shalev 2017).
In responding to these calls, this study makes several contributions to knowledge. Overall, it goes beyond general assertions that military action has a moral impact on soldiers, toward a comprehensive understanding of specific factors at play in deployment-related moral distress, including in military operations other than war. Specifically, this study provides insight into the moral beliefs with which soldiers are deployed and return home, the characteristics of the situations they may encounter on and after deployment, and how they are affected by political practices and public perceptions surrounding their mission. Theoretically, this study’s main contribution lies in advancing the concept of ‘moral injury’, which originated in psychological circles, by contributing to the development and refinement of the concept regarding moral, political and societal dimensions of moral distress. In helping develop this interdisciplinary conceptualization of ‘moral injury’, this study furthers understanding of how the macro-level sociopolitical context of military missions may affect soldiers’ individual experience of military practice, not only in war and combat, as is the focus of current research on ‘moral injury’, but also in peace support missions. In practical terms, this study provides therapists, counselors, military trainers and policy makers with suggestions for how to address moral distress at the individual, military, political and societal level.
Structure of the Dissertation
This Introduction and the next two chapters form Part I, which lays the groundwork for this study. Chapter 2 locates this research in relation to perspectives from various disciplines on the topics of trauma, morality and sociopolitical aspects of mental suffering. It provides both
This Introduction and the next two chapters form Part I, which lays the groundwork for this study. Chapter 2 locates this research in relation to perspectives from various disciplines on the topics of trauma, morality and sociopolitical aspects of mental suffering. It provides both