Invisible Illnesses, Moral Injury, and Shame in Post 9/11 Veterans

Written by: 
Amber Hadley

It’s easy to dismiss irritability, anger, and agoraphobia as a defect of character. PTSD, TBI, and MST can manifest itself in many ways and each patient experiences these conditions in a unique way. Without a limp, cast, disfigurement, or prosthetic, it can be hard to understand just how someone is suffering.

The Difficulties of Living with an Invisible Illness

When an injury, physical or psychological, is invisible to the naked eye people tend to be skeptical. Many fear this stigma and do not want to come forward to look for help because they are afraid of being labeled by their comrades and the general public. Many veterans pride themselves on their fortitude and strength in the face of difficult circumstances – such as combat zones – so the idea of struggling with something they cannot see and sometimes cannot characterize is a difficult reality to face. Many require a catalyst to finally seek help. Divorce, violent confrontations, loss of a job, and unsuccessful suicide attempts, all of these could unfortunately become that catalyst.

 The Difference Between Shame and Guilt

Although both shame and guilt play a large role in post-combat mental illnesses, shame seems to be the largest motivator for problematic behaviors. In a study performed by the VA and the University of Tulsa, which was published by The British Journal of Clinical Psychology, shows that shame particularly contributes to the severity of PTSD.

Guilt is more closely associated with responsibility to specific events or instances. For example, a veteran may feel guilt about harming other enemy combatants and strive to ‘make up for’ or atone for those actions in the future.

Shame, on the other hand, is seen more as a fundamental part of what makes you, well, you. With shame there is an intrinsic belief that not just what you did in the past is ‘bad’, but that who you are in general is bad. With shame there is more of a propensity to isolate yourself in an attempt to circumvent criticism, or to hide who you really are from society. This tendency contributes to the social hardships that PTSD sufferers face.

Shame and Moral Injury

Many veterans who suffer from Posttraumatic Stress Disorder or Traumatic Brain Injury struggle alone for periods of time. During this time, relationships can break down, social supports can disappear, and behavior radically changes. Many veterans feel that these are elements that they should be able to ‘control’ which, without the right tools, is seldom true.

NPR wrote an article in which they interviewed a young veteran named Dexter Pitts, who suffered from PTSD after being deployed in 2004. In it he delved into his story and how he felt facing the fact that, due to the experiences he faced in Iraq, he now suffered from PTSD:

"I didn't really want to accept it," he says.

Pitts says the military had built him up to believe he was "larger than life, almost like a superhero." And if you're anything less than a superhero, "you're weak-minded."

This stigma sticks to our young servicemen and women and acts as a barrier to accessing treatment. 

Because invisible illnesses are not as obvious as physical wounds, they are harder to diagnose and they are the subject of a lot of shame. This shame is correlated with moral injury, which exacerbates PTSD. Moral injury is a common experience for soldiers in combat situations. It can come from fighting enemy combatants or witnessing others get hurt around you. Many soldiers come home with stories of seeing their friends or civilians hurt or killed. Moral injury stems from the idea that there was nothing one could do when confronted with a situation where a deeply held belief or ethic was broken.

Moral injury is commonly associated with self-criticism. Veterans who are afflicted with this often question their self-worth and at times struggle with existential crises. Coupled with PTSD, these thoughts deepen isolation, depression, and in certain instances, substance abuse.

Signs and Symptoms

There are many signs and symptoms for PTSD, TBI, and MST that reveal themselves over time after active duty is finished. Late-onset symptoms are not uncommon, either. Some sufferers do not experience negative symptoms for months or even years after they have left the combat theater. This is called delayed-onset PTSD and at this moment in time, not much is known about it. With nearly a quarter of all PTSD cases thought to be delayed-onset, it is important that we allocate more resources to understand what causes this lag in symptoms (US National Library of Medicine, 2014). Veterans and other professional groups have twice the chance of developing delayed-onset PTSD in comparison of non-professionals.

Inter-Personal Symptoms

Veterans with PTSD are three times more likely to get divorced 2 or more times than veterans who don’t (National Center for PTSD, 2002). This most likely arises from the difficulties that PTSD brings with it. Countless sleepless nights, irritability, and acts of violence can wreak havoc on a marriage.

Combative communication, or no communication, is common sign that sometimes is a precursor to escalated or violent behavior. 63% of spouses of PTSD veterans have faced physical aggression by their partners in the last year. Phycological aggression is higher among suffers as well. Due to these issues, the spouse can experience a ‘ripple’ effect of secondary trauma.

Others suffer from emotional detachment, numbness, and the desire to isolate themselves. Sometimes this numbing comes from the abuse of substances – most notably alcohol or drugs. This numbing can lead to difficulties in giving or receiving affection from loved ones and friends. The pressure of responding to or returning affection can be taxing on someone who suffers from PTSD, so they seek to avoid these situations altogether.

The most common side effects that are reported are as follows (according to the Mayo Clinic):

  • Intrusive Memories: These come as unwanted, persistent memories or flashbacks.
  • Avoidance: Either avoiding places and people or avoiding thinking/talking about traumatic events.
  • Negative Changes in Mood/Thoughts: Pessimistic thoughts about yourself, other people, or the world.
  • Changes in Emotional Reactions: Being always ‘on guard’, becoming easily panicked, being constantly in a state of over-alertness

How We Can Help Our Wounded Veterans

There are many organizations out there that dedicate their time, money, and voice to helping our veterans’ transition into civilian life in a healthy way. However, there has been a lot of criticism of government entities such as the U.S. Department of Veteran’s Affairs, which is accused of not handling cases of invisible illness in veterans well enough.

They commonly are disparaged because of their delays in treatment. The VA is so bogged down in claims that it can take up to a year or sometimes longer to be seen. Sources used in a CNN report in 2013 cited that perhaps up to 20 people died within a year waiting for treatments, and that 1 million dollars allocated to bringing veterans off of waitlists for treatment was misused, with about only one third of the money going to alleviate wait times. Only about 29% of patients were seen within the VA’s projected 14-day window for treatment.

All of this is on top of accusations that the VA pushes medications too readily in lieu of other treatment options. They have recently been criticized for ‘fumbling’ a recent study that plans to measure the effectiveness of service dogs for veterans with PTSD. This VA study, which ran until 2018, stated that they believe service dogs did not have an identifiable positive effect on veterans with PTSD.

Rory Diamond, CEO of K9s for Warriors, believes that the overwhelming bureaucracy of the VA coupled with its unwillingness to change or pay for the care of service dogs is the root of this denial.

"Our warriors use fewer services at the VA, so the overall cost to the government is less (than if they didn't have a service dog), and the warrior is not on pills and is alive," Diamond said. "But dogs cost money and are complicated. The VA is a bureaucracy that doesn't want to change; it's that simple." 

He is quoted as saying in an article written by the American Veterinary Medical Association. In response, K9s for Warriors sponsored a study with Purdue University which resulted in the first scientific affirmation that service dogs helped alleviate, but not cure, symptoms of PTSD.

“If the VA did its job correctly, organizations like K9s for Warriors would not need to exist. The fact that we are here in the first place highlights their failings. With 20 veterans dying a day from suicide, we cannot wait to begin treating our veterans for invisible illnesses.” Mr. Diamond says.

He is right. If you or a loved one is suffering from PTSD, TBI, or MST, encourage them to get help. Every individual serviceman or woman is different and will respond to treatments in their own unique way. However, it is becoming clearer that the modalities that are relied upon today as first line treatment are not working well enough. We need avenues for alternative treatments. All choices should be on the table for every veteran who is suffering.

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