War also inflicts 'moral injury'

WASHINGTON - A veteran of the wars in Iraq and Afghanistan, former Marine Capt. Timothy Kudo thinks of himself as a killer - and he carries the guilt every day. "I can't forgive myself," he says. "And the people who can forgive me are dead."

With American troops at war for more than a decade, there has been an unprecedented number of studies into war-zone psychology and an evolving understanding of post-traumatic stress disorder. Clinicians suspect some troops are suffering from what they call "moral injuries" - wounds from having done something, or failed to stop something, that violates their moral code.

Though there may be some overlap in symptoms, moral injuries aren't what most people think of as PTSD, the nightmares and flashbacks of terrifying, life-threatening combat events. A moral injury tortures the conscience; symptoms include deep shame, guilt and rage. It's not a medical problem, and it's unclear how to treat it, says retired Col. Elspeth Ritchie, former psychiatry consultant to the Army surgeon general.

"The concept . . . is more an existentialist one," she says.

A few years ago, the Marines, who prefer to call moral injuries "inner conflict," started teaching unit leaders to identify the problem. And the Defense Department has approved funding for a study among Marines at California's Camp Pendleton to test a therapy that doctors hope will ease guilt.

But a solution could be a long time off.

"PTSD is a complex issue," says Navy Cmdr. Leslie Hull-Ryde, a Pentagon spokeswoman.

Killing in war is the issue for some troops who believe they have a moral injury, but Ritchie says it also can come from a range of experiences, such as guarding prisoners or watching Iraqis kill Iraqis as they did during the sectarian violence in 2006-07.

"You may not have actually done something wrong by the law of war, but by your own humanity you feel that it's wrong," says Ritchie, now chief clinical officer at the District of Columbia's Department of Mental Health.

Kudo's remorse stems in part from the 2010 accidental killing of two Afghan teenagers on a motorcycle. His unit was fighting insurgents when the pair approached from a distance and appeared to be shooting as well.

Kudo says what Marines mistook for guns were actually "sticks and bindles, like you'd seen in old cartoons with hobos." What Marines thought were muzzle flashes were likely glints of light bouncing off the motorcycle's chrome.

"There's no day - whether it's in the shower or whether it's walking down the street . . . that I don't think about things that happened over there," says Kudo, now a graduate student at New York University. Kudo never shot anyone. But he feels responsible for the deaths of the teens. Like other officers who have spoken about moral injuries, he also feels responsible for deaths that resulted from orders he gave in other missions. The hardest part, Kudo says, is that "nobody talks about it."

Brett Litz, a clinical psychologist with the Department of Veterans Affairs in Boston, sees moral injury, the loss of comrades, and the terror associated with PTSD as a "three-legged stool" of troop suffering.

At Camp Pendleton, the therapy trial will be tailored to each Marine's war experiences; troops with fear-based problems might use a standard PTSD approach; those with moral injury may have an imaginary conversation with the lost person.