Georgetown University philosophy professor Nancy Sherman has spent a career studying ethics, entering the complex territory of military mores, leadership and war in the 1990s when she was tapped to serve as distinguished ethics chair at the U.S. Naval Academy following the Tailhook scandal.

That experience — working with young mids and their seasoned instructors — and a lifetime of watching her father keep secret his experiences in World War II, prompted her to delve deeper into soldiers' psyches, examining not only their mental health but the possible moral conflicts they face after engaging in the profession of war.

Her new book, "AfterWar: Healing the Moral Wounds of Our Soldiers," is her third exploration in that vein, examining the moral struggles of some Iraq and Afghanistan vets and offering guidance on how they may find peace by forgiving themselves and regaining self-empathy. Sherman also addresses changes she feels should be made on an institutional level — in the courts, hospitals and private sector — to help veterans transition to the civilian world and recover from their combat deployments.

Military Times sat down with Sherman prior to a panel discussion scheduled for Monday at Georgetown University to discuss "AfterWar" and the concept of "moral injury," the mental anguish a person feels when something has occurred that transgresses deeply held beliefs.

Nancy Sherman

Photo Credit: Courtesy of Nancy Sherman

Q. What is moral injury?

A. Moral injury is a kind of psychological anguish that can be mild or intense and isn't specific to war but does often come as part of the aftermath of war. It has to do with the reaction to doing wrong, being wronged or witnessing wrongs. For the thinking soldier, war delivers up spades of moral conundrums: Is the fight just? Is calling in this airstrike the right thing to do? Did I protect my troops enough? Did I harm civilians? But it's not just questioning. It's anguish, sometimes crippling shame or guilt. This is not new, it's ancient. Moral rage and anguish goes far back. We see it in Homer, when Achilles, angry over the death of his friend, drags Hector's body around from the back of his chariot. In clinical medicine, moral injury often gets ignored in favor of the slimmer notion of psychological trauma, which primarily is fear-based. This goes beyond the medical model; it's the spiritual and mental anguish some experience when they go to war.

Q. Does it play a role in combat-related mental health conditions, like post-traumatic stress disorder or depression?

A. Moral injury is a psychological injury, so it is a type of mental health condition. It can rise to the level of having a totally shattered moral identity. It is one of the many psychological traumas that can have a spiraling effect, leading to dissociation, self-medication, depression and anxiety. It can mix with the usual symptoms of PTSD such as hyper-vigilance and flashbacks. But it's not right to think of this solely as pathological or medical. So much of the mental well-being of troops doesn't fall under a medical model. Much work is to encourage public engagement so the experiences of war don't get bottled up and lead to a medical condition.

Q. Can, or should, it be treated?

A. The folks working in therapeutic and clinical settings are looking at protocols for treatment that may be distinct from the standard protocols for PTSD. There is evidence to suggest that cognitive therapy — a common treatment for PTSD — may not be the best clinical method for dealing with issues that are not fear, but are guilt, shame, remorse and undermining of trust. There may be ways of thinking about it that don't focus on extinction of fear, which is what a lot of therapies are about. It may be that those with moral injury need to develop a kind of self-empathy, of cultivating a way of being less hard on themselves, especially in cases of survivor's guilt or feeling like you did wrong.

Q. If troops don't come home from war with these feelings, would that be a concern?

A. The human mind is terribly individual; there's no universal soldier. We all have different backgrounds, thoughts, reactive attitudes. Some may be more affected by what they see than others. While it would be peculiar if someone is so callous they don't grieve a loss or perhaps question whether they've done all they could do, we also owe a debt to those who can go to war and accomplish the mission, do it well and are able to come home and carry on. Everyone reacts differently to circumstances, and no one way is "normal."

Q. What is your hope for "AfterWar"?

A. I'm interested in creating a conversation that starts to heal the military-civilian divide through engagement. This is really about trying to understand the ongoing reintegration challenges. The largest group of veterans who have served our country since Vietnam are home and we need to help them. I think much of the point is to tear down walls, helping the military understand that civilians can help them and helping civilians (understand that) troops are members of the community ... to bring these groups together. If I have some tools to help facilitate this, I want to. Moral conflicts are conundrums that are not easy to express. I want to be able to help make some sense of it all.

Patricia Kime is a senior writer covering military and veterans health care, medicine and personnel issues.

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