Moral injury is a wound to the conscience, and nothing inflicts it more deeply than war. Here's how one veteran found healing after a traumatic event in Iraq.
Posted in , Apr 18, 2017
I sensed the gazes of the three other guys, all fellow veterans, on me. But I couldn’t look them in the eye. I stared down at the pages in my hands.
The four of us sat across from each other. This was our third week in group therapy at a military residential treatment program in San Diego, California—one of the first of its kind—with the hope of finding relief from the torment, the guilt that had been consuming us.
Moral injury—that’s what the shrinks here called it. Living with the knowledge that you’ve done something awful, a violation, if not of the law, then of your own code of conduct. All I knew was that I had nowhere else to turn. Even God, it seemed, was through with me. I couldn’t blame him.
I’d spent a week laboring over this assignment, to write about the very thing I’d tried for years to forget. “Don’t hold back,” the therapist had said. “Tell us everything.”
I took a deep breath. “It was just another bloody day in Mosul....”
I never expected to end up in Iraq. I’d grown up on a farm in Crescent, Oklahoma. My father died when I was seven, leaving my mother with eight kids to raise. “God will provide,” she said. “Everything happens for a reason.”
How could she be sure? “Marshall,” she’d say, “you’re always going to be short on faith. You’re not Jesus.”
Right out of high school, in 1976, I enlisted in the Air Force. The only way to escape a life of poverty, I thought. I got assigned a desk job and served eight years. Out of the military, I struggled. So I joined the Army. Studying to be a licensed practical nurse, they told me, would mean a big increase in pay.
I didn’t know a thing about being a nurse, but I could use the pay. By the time I graduated nursing school in 1995, I knew what my mother had meant about things happening for a reason. I’d found my purpose. The feeling I got caring for patients was like nothing I’d ever known. Making my rounds, I talked to God, telling him what I was doing, praying for each patient. Not everyone got better. I wept anytime a patient died. But I understood. Only God knew when it was someone’s time to go. I didn’t struggle with that concept.
I was stationed at Tripler Army Medical Center in Honolulu. I worked in surgery and cardiology. I didn’t get to see my family in Oklahoma much. Mostly I stayed in touch through letters and pictures, and I was especially fond of one niece.
By 2005, I was the noncommissioned officer in charge of the Acute Care Clinic nursing staff. The wars in Iraq and Afghanistan were under way. Doctors and nurses were being sent over. I was anxious to do my part. In the spring of 2006, I got the call.
That’s how I ended up at a combat hospital in Mosul, Iraq. The fight to wrest control of the city away from Al Qaeda forces was at full throttle. I was the NCO in charge of the ICU. In theory, my job was to direct the nursing staff and manage supplies. In reality, all any of us did was treat a never-ending flood of casualties.
It felt hopeless. Human beings being put through agony. Twelve months into a 15-month deployment, I’d seen more blood than I had in 11 years of nursing stateside. “Why am I here?” I’d yell at God. “Why can’t you make this better?”
In the group therapy room, I hesitated, still not daring to look at the other guys. No one said a word.
“Just after midnight on August 12, 2007, we heard a bomb go off,” I read. My chest tightened at the memory.
Trucks pulled up, loaded with casualties—Iraqi civilians, badly burned, blood everywhere. Some already dead. We had only 10 beds. There were at least three times that many casualties. It was on me to decide who would be treated. I triaged, pointing to the people I thought we’d have the best chance of saving. The rest we’d try to get to, but I knew there would be little hope of that happening.
We tended to the most urgent cases. Nearly an hour passed before I saw her. A tiny Iraqi girl lying on a blanket in the hallway. She couldn’t have been more than six years old. Burned, covered in blood. She was dying, and I could do nothing. She let out deep moans. Even in agony, she had a sweetness to her face that reminded me of my niece back in Crescent. Still, I wanted to cover my ears from the terrible moans.
I have to ease her suffering, I told myself. This girl’s really hurting. I got a syringe filled with morphine, several doses. I set up an IV and pressed dose after dose into it, enough to...
I stared down at the words I had written. The memory that had haunted me every day since, for more than six years. “She smiled at me,” I said. “I smiled back and told her it was gonna be okay. Then she took her last breath and was gone.”
I killed that little girl.
I took her broken body to the morgue. Then I went to my office and sobbed. I tried to tell myself I’d done the right thing, but I was besieged with doubt. This innocent child who should have never been in the midst of a war zone... I’d stolen her last moments. As if I were God. Yes, there was absolutely nothing we could have done to save her. She was suffering horribly. I knew what I was doing with that syringe loaded with morphine. But wasn’t “do no harm” the first principle of medicine? Wasn’t my purpose to heal?
Three months later, I was home in Hawaii. I struggled to get back to my old routine. But my work no longer had the same meaning. As much as I had hated life in Iraq, I missed the intensity. The full-on adrenaline rush, like an addiction. Overhearing people complain about life’s meaningless inconveniences set me off. I was angry all the time. I felt so alone.
One night, in my sleep, I saw her. The girl. Her face looking up at me, just before she died. I woke screaming.
Night after night, the girl haunted my dreams, until I was afraid to go to sleep. There was no one I could talk to. Others hadn’t been there. They wouldn’t understand.
I started drinking to get to sleep. To ease this agony of the conscience. At work I was able to function. Barely.
I knew I couldn’t go on like this. I went to a shrink. She prescribed some meds. We talked. I opened up to her. For the first time in months, I was able to sleep. A year later, I was transferred to Alaska. The nightmares returned. I couldn’t find a therapist I could trust. I dreaded having to tell my story all over again. Maybe this was God’s way of punishing me. Maybe I deserved to feel this way.
I thought about killing myself. I had put the little Iraqi girl out of her fatal misery. Why not put myself out of mine? Finally I went to another therapist, my fifth in five years.
“I’m done talking,” I told the shrink.
“I understand,” she said. “I’ve read your files. There’s a ten-week residential program in San Diego. You should consider it.”
That’s how I’d ended up here in therapy with three other vets. There were eight of us in the program overall. For the first two weeks, I’d met daily with a therapist, talking through the responsibility I felt for that Iraqi girl’s death, the idea that one experience didn’t define my entire life, breaking down what had happened, reminding myself that I’d had the best of intentions.
It was my therapist who explained about moral injury, a relatively new concept in the mental health field. There was debate over whether it should be a formal diagnosis. But for me, just knowing there was a name for my suffering, an explanation, gave me hope.
I’d gotten to know the other guys, gone for long walks with them. Spent time in prayer—for the first time in years. And now this, telling my story, the assignment I’d dreaded.
I looked down again at what I’d written. “God, forgive me,” I said.
Silence. I chanced a glance at the guys. Their heads were bowed, their gazes trained on the floor. Then one of them, an Army staff sergeant who’d been too traumatized to come to the aid of a fellow soldier under fire, jumped to his feet and extended his hand. “You didn’t do anything wrong, Marshall,” he said. “You did your best.”
A simple handshake from someone who knew how I felt. It was as if God was taking my hand, telling me it was okay to be angry, to feel hurt, to be short on faith. To be human. Telling me that he forgave me.
The other vets read their stories—all the tales harrowing. Hearing those voices, full of the same pain as mine, made me finally understand I was not alone.
We were given one last assignment. To write a letter of apology to the family of the person we felt we’d wronged. I had no way of actually contacting the girl’s family. Still I wrote, “I want you to know your daughter has been in my heart each day since that night.”
Four months after I finished the program, I was honorably discharged from the Army. I could have retired to Hawaii. Instead I moved to Crescent, back to my family farm. A place where I could continue my recovery. I work the land, keeping up a conversation with God as I go. And I’ve gone back to nursing at a home for the elderly. The other vets from therapy and I stay in touch, online and in our hearts. We remember that healing comes from leaning on each other and that none of us is alone.
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