Trauma Psychology News

Suicide Prevention in the Context of Moral Injury & the Afghanistan Withdrawal

Dustin Lewis
Dustin Lewis

Dustin Lewis

Section Editor: Antonella Bariani
Peer Reviewers: Linda Zheng & Molly Becker

In August of 2022, I separated from the Air Force after nearly 11 years as an officer. I immediately transitioned into a master’s program in Counseling Psychology at the University of Wisconsin–Madison, with the intention of working with veterans. The most recent United States Census Bureau data shows that there are approximately 18 million veterans in the United States, representing roughly 7% of the US population (Bureau, 2022). Military service members and veterans typically experience significant physical and psychological challenges. In the context of these challenges, veterans are at an increased risk of exposure to morally injurious events, which has been associated with an increased risk for suicidal behavior (Bryan et. al., 2014; Nichter et. al., 2021).

One of the many reasons why I started down the path of separating from the military and providing counseling to veterans was my own experience of moral injury and being surrounded by far too many suicides (one is more than enough). My decision to leave the military involved a lot of factors. One of them was the American withdrawal from Afghanistan in 2021 and the moral injury that event imparted on me and many of my friends and peers.

The Department of Veteran’s Affairs (VA) describes moral injury as follows: “In traumatic or unusually stressful circumstances, people may perpetrate, fail to prevent, or witness events that contradict deeply held moral beliefs and expectations: (1) When someone does something that goes against their beliefs, this is often referred to as an act of commission, and when they fail to do something in line with their beliefs, that is often referred to as an act of omission. Individuals may also experience betrayal from leadership, others in positions of power or peers that can result in adverse outcomes. (2) Moral injury is the distressing psychological, behavioral, social, and sometimes spiritual aftermath of exposure to such events. (3) A moral injury can occur in response to acting or witnessing behaviors that go against an individual’s values and moral beliefs” (Norman & Maguen, 2020).

In my own words, moral injury occurs when you do something you do not want to do, in extreme circumstances where the only other options are also things you do not want to do. Often, moral injuries are defined by split-second decision making under demanding and unsettling circumstances (Barnes et. al., 2019).

Prior research has discussed the strong associations between exposure to morally injurious events and suicidal behavior (Bryan et. al., 2014; Nichter et. al., 2021; Wisco et. al., 2017). There are many challenges that follow experiencing these types of events. For me, moral injury, combined with PTSD, has manifested as stress, anxiety, depression, insomnia, and other intrusive experiences that are typically grouped under the general label of Post-Traumatic Stress Disorder (PTSD). While symptoms of PTSD and moral injury often overlap and simultaneously exist, trauma research has noted distinct differences between the two (Barnes et. al., 2019). PTSD is typically conceptualized as a fear-based disorder, while moral injuries are based on the internal perception of a violation of one’s morals and often develops after the event has ended (Barnes et. al., 2019).

According to the United States Center for Disease Control (CDC), “Veterans bear a disproportionate but preventable burden.” Tragically, “out of the 130 suicides per day in 2019, 17 of those lives lost were veterans” (CDC, 2022, para. 3). Specifically, veteran suicide-related deaths have increased at a greater rate than those of the general U.S. population, with research demonstrating 36% and 30% increases in suicide rates respectively (CDC, 2023; U.S. Department of Health and Human Services, n.d.).

Unfortunately, this is a reality that many veterans face as they navigate life after service. The majority of my time in the military was spent as a navigator on the AC-130 gunship, a heavily armed cargo airplane that has a rich and humbling history, and has been honed into a devastating tool of war. In my role as a navigator, my voice was one of the final pieces in a complex process of checks and balances that needed to be met before a bullet ever left our aircraft. During one of my many combat missions, my crew engaged a target that was a significant threat to the ground force that we were supporting. It was later confirmed that our target was valid and our engagement was justified. It was also confirmed that civilians, including women and children, were killed during this engagement. This was a moral injury to me. My effective use of the knowledge and skills that I had worked so long and hard to obtain had led me to contribute to the death of innocent civilians. This is a part of war and hearing that does not make it any easier to live with.

During the infamous withdrawal of American troops from Afghanistan in August of 2021, a friend of mine commanded a gunship crew flying over Kabul on August 16th. He watched from the sky as the events unfolded that led to the tragic takeoff of a C-17 aircraft laden with people holding onto the outside, clinging to any hope of escape (Cohen, 2022). My friend watched these events unfold with very little guidance on how he was expected to respond. He knew members of the crew flying that C-17 and had to grapple with the choice of watching a military aircraft overloaded with civilians crash and possibly kill everyone on board, or if he needed to command his crew to fire into the overwhelming mass of innocent people to prevent that. There’s no clear, simple answer for how to behave in that circumstance. And now my good friend and the rest of that crew are likely carrying that unique moral injury around every day. I watched the events in Kabul unfold from a hotel room on the first night of a two-week road trip, the day before I officially made my decision to separate from the military after contemplating the idea for over a year.

Living with moral injury is a unique and distinct experience. I do not have an answer for how to best address these issues and, for me, working through them is a daily occurrence. Going forward, future research is needed to better understand moral injury and its role in suicide prevention. My main concern in writing this article is that we have a current generation of veterans from Iraq and Afghanistan (myself included) who are being treated with outdated protocols. It is also particularly important for mental health researchers and providers alike to understand and distinguish the impact of moral injury on suicidal tendencies, within the context of interaction with PTSD. Finally, it is imperative that we all demonstrate grace and compassion to those around us, as many are carrying invisible burdens and experiences that we may never understand.

DUSTIN LEWIS is a first-year student in the two-year master’s in counseling psychology program at the University of Wisconsin–Madison. He is currently the Vice President of the Student Veterans of America chapter in Madison, WI. Dustin was born and raised in Eagle River, Wisconsin and received his bachelor’s in Psychology from UW–Madison in 2011. He then joined the Air Force and spent most of his career in the military as an AC-130U Navigator at Hurlburt Field, Florida.

Citation: Lewis, D. (2023). Suicide prevention in the context of moral injury and the Afghanistan withdrawal. Trauma Psychology News, 18(1), 34-36.

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