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Can a new diagnosis help to heal our souls?

On moral injury:

War correspondent Janine di Giovanni writes in Harpers about the revelation to South Africa-born Toronto psychiatrist Anthony Feinstein of the “deep and sustained trauma” suffered by a war reporter who consulted him after returning from a particularly gruesome assignment in a conflict zone. He wondered whether proper training before her assignment or early intervention after her return could have alleviated her profound suffering.

In the late 90’s, before PTSD was a well-known concept, the idea of a conflict reporter suffering from the disorder was unfamiliar. The 90’s were a decade characterized by wars in Africa, the Balkans and the Middle East, which often involved extreme violence and atrocities by lawless paramilitary groups. War reporters, not yet embedded with troops, were freelancers and had no protection, no insurance or security guards, and no conflict training. They were regularly killed or permanently injured and a significant number took their own lives.

Feinstein decided to study PTSD among war reporters, interviewing over a hundred including di Giovanni, and was alarmed by his findings.

‘ “I do not believe there is another profession that has more exposure to war than your group,” he told me. While soldiers often served one or two tours, he said, “You go back year after year after year to war.” Feinstein compiled a database of more than a thousand frontline journalists and concluded that the mean time spent in war zones for career war reporters was nearly fifteen years.’

Feinstein’s findings of the prevalence of PTSD in his subjects was published in the American Journal of Psychiatry in 2002. Feinstein started a full court press with the press to persuade editors to pay attention to their war correspondents’ trauma, prompting many leading news organizations to develop conflict-reporting protocols.

In the 2010’s reporters covering the refugee crisis, who were not themselves at risk of being shot on the front lines, were suffering a new kind of mental health crisis from their profound helplessness and inability to save the tragic drowning victims or alter the circumstances driving them from their homes. He believed these journalists were suffering from moral injury, a term with origins in Jonathan Shay’s 1994 study of veterans with PTSD, Achilles in Vietnam: Combat Trauma and the Undoing of Character. Recent studies have established that moral injury, which can co-occur with PTSD but is distinct, has emerged as the

‘biggest psychological challenge confronted by journalists covering the migration crisis…

Feinstein describes it as “a wound on the soul, an affront to your moral compass based on your own behavior and the things you have failed to do.” In other words, this is triggered by one’s feeling of having failed to live up to one’s own ethical standards rather than by external events. For instance, it is common for photographers shooting human catastrophes to feel that they have benefited from the suffering of their subjects, documenting instead of intervening. A complicating factor, especially for American journalists, is the feeling that one’s own country is contributing to or responsible for the suffering observed.

Moral injury of course is not restricted to journalists — soldiers who have witnessed torture (e.g. Abu Graib), doctors working in war zones, survivors of school massacres, prosecutors who feel ineffectual in righting injustice, witnesses of police brutality, are all vulnerable. It strikes me that it is a particular malignant and poignant form of survivor guilt.

Feinstein believes that medical professional might be among the most susceptible. Understanding moral injury will be important to address the problems faced by frontline healthcare workers who risked their lives and were powerless to save so many others during the CoViD crisis, in some cases making guilt-inducing decisions about who lived and who died themselves.

‘And what about the community at large? Will we all suffer from moral injury given what we have witnessed during the pan- demic? Feinstein thinks the predomi- nant emotion will be anxiety, but that people will experience degrees of moral injury. He told me to think of a hierarchy of suffering. Those who have lost people they loved place at the top, and below them are those who lost a business or a chance to celebrate a life milestone such as a wedding or a grad- uation. “These too will leave their mark,” he said.’

Finally, Feinstein speculates on the longterm effect of feeling moral revulsion toward the behavior of the man who is supposed to be our president. As FDR said, ‘The presidency is not merely an administrative office . . . it is preeminently a place of moral leadership.’ Today, those surviving and bearing witness may experience intense guilt about their powerlessness to mitigate the suffering and disaster inflicted by the Mad King.

After identifying the disorder and its scope, Feinstein is turning his attention to sources of resiliency and potential treatments. Is it possible to repair a soul?