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moral injury

Working as a therapist near a Seattle-area military base, Sebastian Perumbilly saw many post-9/11 veterans struggling to readjust to civilian life. Traumatized by their combat experiences, they often complained of nightmares, insomnia and depression. Some self-medicated with alcohol or illegal drugs.

At the time, Perumbilly treated them for post-traumatic stress disorder, like most clinicians would have back in 2010. But today he believes some may have been suffering from a different post-combat condition: “moral injury.”

Recognized by clinicians only recently, “moral injury” occurs when soldiers do or witness something in combat that violates their own values or society’s moral code. While many symptoms overlap with PTSD, veterans suffering from “moral injury” also experience deep feelings of shame, guilt and remorse.

“A part of you dies. That’s what these veterans tell us,” said Perumbilly, now assistant professor of marriage and family therapy at Southern. “They don’t want to do certain things, but they are forced to,” causing a crisis of conscience. He said traditional mental health tools, such as psychotherapy and medication, do not heal these deeper wounds.

Perumbilly recalls one post-9/11 veteran he met in Seattle who complained of devastating nightmares. The veteran was haunted by memories of running over three Iraqi children who formed a human barricade in front of his military vehicle, blocking its path.

“He killed all three of them, but at the same time he had three kids back home almost the same age – 11, 9 and 7,” Perumbilly recalled. “He said each time he went to sleep, these kids were screaming in his head.”

He now cites the veteran as a textbook example of moral injury. Even though he was trained to act the way he did based on the military’s rules of engagement, Perumbilly said, he felt enormous guilt as a father and human being.

“While you are in combat, the rules of engagement are different (from the rules of society).When you are out in the field, you don’t know what’s waiting for you. You have to kill or be killed,” Perumbilly said. “But still it affects you when you come back.”

Perumbilly first learned about moral injury while looking into the high rate of suicide among post-9/11 veterans. An estimated 20 veterans per day die by suicide in the U.S., according to a 2014 study by the Department of Veterans Affairs.

Working under a grant with Valerie Dripchak, professor of social work at Southern, he set out to learn more about the phenomenon. His research led him to Edward Tick, Ph.D., one of the nation’s leading experts on moral injury and founder of Soldier’s Heart, a program that promotes “spiritual and holistic” healing.

Last November and December, Perumbilly spent two weeks in Vietnam with Tick and a group of Vietnam veterans on a “reconciliation journey.” The idea was to return to the place where the injury occurred so the soldiers, now in their 60s and 70s, could make peace with their past. Two post-9/11 veterans also made the trip.

One veteran wanted to go back to the Mekong Delta, where he recalled killing “anything that moved” in a firefight. Another, a Mennonite gardener, told how he was ordered to drive a truck through a rice paddy in an act of destruction, over the cries of Vietnamese women and children.

“We went back to the same exact spot. He removed his shoes and walked through the rice paddy,” said Perumbilly, who was there as an observer and researcher. “It was a very powerful, deeply spiritual, moving experience.”

The vets also met with former Viet Cong soldiers, and were surprised – and relieved– at the welcome they received and to learn the country has moved on.  Perumbilly has kept in touch with the veterans, who told him the trip did more for them than decades of treatment for PTSD. He hopes to share the lessons he learned with the future therapists he teaches at Southern.

“The conventional wisdom we have in psychology and mental health is not sufficient to treat this population,” he said. “They’re in a different world.”