PORTLAND, Maine — Post-traumatic stress disorder has become so familiar among the many difficulties veterans face after returning from war that most know it by its acronym — PTSD.
But the diagnosis reflects only part of the broader psychological harm soldiers bring home from the battlefield, according to Dr. Jonathan Shay, a nationally recognized psychiatrist and author of two books on combat trauma and the trials of homecoming for veterans and their families.
Shay’s visiting Maine this week to meet with veterans groups and their supporters, and he will give two public addresses on Wednesday at the University of Maine. He spoke to members of the Maine State Bar Association and the Maine Judiciary in Portland on Tuesday.
Shay views the experiences of combat veterans from perspectives found in two great works of literature, Homer’s “Iliad” and “Odyssey.” A recipient of a MacArthur Foundation “Genius Grant,” he wrote “Achilles in Vietnam: Combat Trauma and the Undoing of Character” in 1994, followed by “Odysseus in America: Combat Trauma and the Trials of Homecoming” in 2002.
Shay coined a new term — “moral injury”— to capture what a PTSD diagnosis leaves out. Some hope that it, too, will join the common lexicon.
The hallmark symptoms of PTSD — nightmares and flashbacks, withdrawal from society and interests, hyper-arousal to anticipated dangers — are useful from an evolutionary perspective but destructive in civilian life, he said.
“PTSD, as defined by the American Psychiatric Association, is not a bad summary of what it looks like when other human beings have been trying to kill you and doing a damn good job of it,” he said in an interview.
Beyond the immediacy of mortal danger, however, service members face psychological wounds when the realities of war conflict with a communal sense of right and wrong, Shay said. Unable to reconcile the two, many descend into a “terrible state of being” upon returning home, he said.
Moral injury, as Shay defines it, results when a leader who holds legitimate authority betrays what’s commonly accepted as right, in a high-stakes situation.
Imagine an infantry squad surrounded by the enemy, he said, tormented by a sergeant’s order to retreat while a fellow soldier lays wounded and screaming. For service members instilled with the concept of “leave no man behind,” that presents a moral crisis, he said.
It also reflects another form of moral injury, advanced by other researchers in the field, in which soldiers betray their own sense of morality, Shay said. Obeying the order and abandoning a comrade could leave a solider with crippling guilt and shame.
Even witnessing or learning of such an event can prove harmful, he said.
While moral injury isn’t a formal diagnosis, like PTSD, sufferers physically reel from the pain of a crumbling moral foundation, Shay said.
“The body reacts massively,” he said. “The body codes moral injury as physical attack.”
The damage to the mind and spirit can persist for years, fueling deep mistrust that dismantles veterans’ social relationships, Shay said.
“It just devastates the capacity to have a good human life,” he said. “When trust is destroyed, it doesn’t leave a vacuum, it doesn’t leave nothing. When trust is destroyed, it leaves behind the active expectancy of harm, exploitation and humiliation.”
Some sufferers choose to strike first. During his 20 years as a staff psychiatrist in the Department of Veterans Affairs outpatient clinic in Boston, sometimes “a veteran I had never previously met comes through my door on the attack before he’s even set foot in my office,” Shay said.
Others cut off contact, living in isolation, or hide behind manufactured identities and lies, he said.
Anyone who works with veterans, from employers to government agencies, would be well-served to keep these struggles in mind, he said.
In Maine, about one in 10 residents is a veteran, giving the state one of the highest populations of veterans per capita in the nation. Nearly three-quarters of them served during wartime.
Organizers of Shay’s visit to Maine hope to raise awareness about combat veterans’ experiences, train health providers to better serve them, foster ethical leaders, and forge new ways to deal with PTSD and other combat-related injuries.
Shay’s visit to Maine is sponsored by the Maine Military & Community Network, Maine Infantry Foundation, Acadia Hospital, the University of Maine Humanities Center, the Bangor Daily News, and the law firms of Verrill & Dana in Portland and Vafiades, Brountas & Kominsky in Bangor.
