“Guilt is the root of it,” he said. “Asking yourself, why are you such a bad person?” He wasn’t that way before his military service. “I have a hard time dealing with the fact that I’m not me anymore.”

“Everybody has demons, but there are some wild kind of demons when you come back from combat,” said a Navy corpsman (the Navy’s name for its medics) who served a tour each in Iraq and Afghanistan and asked not to be identified by name. He was once unable to save a Marine with a terrible head wound, and afterwards felt other Marines blamed him. “You come home and ask yourself, what the hell did I do all that for? You gotta live with that shit and there’s no program that the military can send you to or any class that’s really gonna help.

“You come home and ask yourself, what the hell did I do all that for?”

Therapists and researchers are recognizing more and more cases of service members like Grimes-Watson who are returning from war with moral injuries, wounds caused by blows to their moral foundation, damaging their sense of right and wrong and often leaving them with traumatic grief.

Nearly a decade later, Grimes-Watson is haunted by the war and her part in it, bearing moral injuries literally so unspeakable that she seems beyond help. “I avoid talking about it, try to keep it down,” she told me in a recent phone conversation. “But inside I’m trying to do the happy face so no one knows how much I’m hurting.”

Occasionally she would call home, but would burst into tears when she’d start to describe what she was doing. Then she stopped trying. A young officer in her platoon, Ben Colgan, was fatally wounded in a bomb blast. She was devastated. “I couldn’t help Lt. Colgan,” she told the military newspaper Stars and Stripes in 2004.

Billie Grimes-Watson was a medic in Iraq in 2003 and 2004. As the initial U.S. invasion turned into bloody chaos, she would sprint through through the smoke and fire of blasts from improvised explosive devices and gunfire to save lives, struggling with the maimed and broken bodies of soldiers she knew and loved. And try to recover in a few hours rest between missions.

Few life traumas can match the experiences of a medic in combat, or etch so deeply and painfully into a soul.

But by and large, those with moral injury are on their own.

“It was sort of a ritual of forgiveness,” said the chaplain, Lt. Col. Doug Etter of the Pennsylvania National Guard. “The idea was to leave all the most troubling things behind in Iraq.”

On the battlefield, some have devised makeshift rituals of cleansing and forgiveness. At the end of a brutal 12-month combat tour in Iraq, one battalion chaplain gathered the troops and handed out slips of paper. He asked the soldiers to jot down everything they were sorry for, ashamed of, angry about or regretted. The papers went into a makeshift stone baptismal font, and as the soldiers stood silently in a circle, the papers burned to ash.

“Medication doesn’t fix this stuff,” said Army psychologist John Rigg, who sees returning combat troops at Fort Gordon, Ga. Instead, therapists focus on helping morally injured patients accept that wrong was done, but that it need not define their lives.

The therapies and drugs developed to treat PTSD don’t get at the root of moral injury, experts say, because they focus on extinguishing fear. PTSD therapy often takes the form of asking the patient to re-live the damaging experience over and over, until the fear subsides. But for a medic, say, whose pain comes not from fear but from losing a patient, being forced to repeatedly recall that experience only drives the pain deeper, therapists have found.

Only one small program, based at the San Diego Naval Medical Center, routinely provides therapy designed for moral injury. Several clinicians launched the program early in 2013 after realizing that many of their PTSD patients needed a different kind of help.

For most veterans with moral injury, there is little help. In contrast to the extensive training and preparation the government provides troops for battle, the Defense Department and the VA have almost nothing specifically for the moral wounds that endure after they return.

“People mostly try to push those experiences away and not look at them, and they inevitably end up with an oversimplified conclusion about what it all meant,” he said. “We’re trying to get them to unearth the beliefs that are causing their distress, and then help them analyze it, consider the evidence for and against the way they see it, and ultimately develop a more nuanced belief about what happened and what their responsibility actually is.”

“People try to make sense of what happened, but it often gets reduced to, ‘It was my fault,’ ‘the world is dangerous,’ or, in severe cases, ‘I’m a monster,’” explained Peter Yeomans, a staff psychologist at the VA Medical Center in Philadelphia. Many of his patients suffer from both Post Traumatic Stress Disorder and moral injury, and he is searching for ways to ease their pain.

“People try to make sense of what happened, but it often gets reduced to, ‘It was my fault,’ ‘the world is dangerous,’ or, in severe cases, ‘I’m a monster.’”

For others, the wound gets worse. For Tremillo, “there is no fairytale ending,” he said.

For many who experience such moral injury, the shock and pain fade over time. Supportive and understanding family and friends, a good job and often a spiritual connection can help.

American soldiers had to act that way, Tremillo recognizes, “in order to stay safe.” But the moral compromise, the willful casting aside of his own values, broke something inside him, changing him into someone he hardly recognizes, or admires.

“As I watched I could feel in my own limbs and chest the shame and fury” of the helpless civilians, he wrote.

In Iraq, where Tremillo served his first combat tour, it was common for U.S. troops to search for weapons caches by banging on a door and ordering a family out of the house, holding them prone on the ground at gunpoint while rifling through their belongings. It was an oft-repeated scene, one that former four-star military commander Stanley McChrystal wrote in his memoir made him feel “sick.”

Marine Staff Sgt. Felipe Tremillo also is struggling with guilt. Two years after he came home from his second combat tour, Tremillo is still haunted by images of the women and children he saw suffer from the violence and destruction of war in Afghanistan. “Terrible things happened to the people we are supposed to be helping,” he said. “We’d do raids, going in people’s homes and people would get hurt.”

In a recent phone conversation, however, Litz said moral injury has become a significant area of interest among clinical scientists. “What’s new is that we are trying to study it in a more scientific way and finding ways of treating moral injury – and that’s unprecedented. It’s a slow process, and I am very proud of the fact that we have brought science to bear,” he said. Speaking of the results of new research on experimental therapies, he added: “You can’t argue with a clinical trial.”

But things are changing. As recently as 2009, Litz was writing that despite evidence of a rising tide of moral injury among troops from the wars in Iraq and Afghanistan, clinicians and researchers were “failing to pay sufficient attention” to the problem, that “questions about moral injury [were] not being addressed,” and that clinicians who came across cases of moral injury were “at a loss” because existing therapies for PTSD were not designed to address moral injury directly.

“Moral injury is a touchy topic, and for a long time [mental health care] providers have been nervous about addressing it because they felt inexperienced or they felt it was a religious issue,” said Amy Amidon, a staff psychologist at the San Diego Naval Medical Center who oversees its moral injury/moral repair therapy group. “And service members have been very hesitant to talk about it, nervous about how it would affect their career.”

Litz accepts the military’s reluctance to recognize moral injury. “I’m very respectful of how difficult it is for them to embrace,” he said. “After all, service members have to follow orders, and if ordered to do something it is by definition legal and moral.” Difficult problems might arise from official recognition of moral injury: how to measure the intensity of the pain, for instance, and whether the government should offer compensation, as it does for PTSD.

Mental health care providers “often address moral injury when treating a psychiatric disorder,” the statement said, and chaplains are available as well. Crabaugh would not say why Pentagon policymakers refused to discuss moral injury.

The Pentagon declined to make policymaking officials available to discuss moral injury. Instead, Defense Department spokeswoman Joy Crabaugh issued a statement observing that moral injury is “not clinically defined” and that there is no “formal diagnosis” for it. The statement said the Defense Department “provides a wide range of medical and non-medical resources for service members seeking assistance in addressing moral injuries.”

“That’s a euphemism,” snorted retired Marine Maj. Gen. Thomas S. Jones, a decorated combat veteran who has had to raise his own money for research into combat stress, moral injury and treatment for wounded Marines . “It is true the folks are loath to use the word ‘moral,’” he said of military brass. Those outside the military “will think it means somebody did something immoral,” which may not be the case, he said.

The military services, not surprisingly, are reluctant to discuss moral injury, as it goes to the heart of military operations and the nature of war. The Army is producing new training videos aimed at preparing soldiers to absorb moral shocks long enough to keep them in the fight. But the Pentagon does not formally recognize moral injury, and the Navy refuses to use the term, referring instead to “inner conflict.”

Military services, not surprisingly, are reluctant to discuss moral injury, as it goes to the heart of military operations and the nature of war.

A few academic researchers and therapists scattered across the country are experimenting with new forms of therapy, some adapting ideas that have worked with patients suffering from PTSD and other forms of war trauma. The Pentagon has quietly funded a $2 million clinical trial, led by Litz, to explore ways to adapt PTSD therapies for Marines suffering from moral injury.

Brett Litz, a clinical psychologist and professor at Boston University who is affiliated with the VA in Boston, has done pioneering work in defining and treating moral injury. “We have no illusion of quick-fix cure for serious and sustained moral injury,” he said.

‘I See Incredible Goodness’

At the San Diego Naval Medical Center, the eight-week moral injury/moral repair program begins with time devoted simply to allowing patients to feel comfortable and safe in a small group. Eventually, each is asked to relate his or her story, often a raw, emotional experience for those reluctant to acknowledge the source of their pain. The idea is to drag it out into the open so that it can be dealt with.

“We are not going to brush it aside. It did happen and it wasn’t OK. The point is to help them feel OK sitting in the darkness with the evil they experienced.” Amy Amidon, psychologist

The group is instructed to listen and respond with support but not judgment, neither condemning nor excusing what happened. Whatever caused the moral injury, Amidon said, “we are not going to brush it aside. It did happen and it wasn’t OK. The point is to help them feel OK sitting in the darkness with the evil they experienced.”

Often, patients feel guilty or ashamed, convinced they are unforgiven, worthless and impure.

In one recent session, a soldier rose hesitantly and told of a firefight in Iraq. Insurgents had suddenly rushed toward him using women and children as shields. “He had about three-quarters of a second to decide, and of course he killed,” Michael Castellana, a staff psychotherapist and co-facilitator of the group, recounted.

“When he arrived home, coming off the plane, his wife handed him his new baby daughter. She put the baby in his arms and he immediately gave the baby back to her with an almost disgusted look – he almost dropped her,” he said. “The thing was, his new daughter was so beautiful and perfect and pure that he didn’t want his filth to contaminate her.

“As terrible as some of this stuff is – and sometimes what we hear makes your toes curl – what I see in these people is incredible goodness,” Castellana said. “Their efforts to punish themselves is just further evidence of their goodness.”

Further into the sessions, group members are encouraged to do community service, and to practice acts of kindness. “One of the consequences of moral injury is self-isolation,” said Amidon. “The idea here is for them to begin to recognize the goodness in themselves, and to reinforce their sense of being accepted in the community.”

Toward the end of the eight weeks, group members are invited to write a letter to themselves from a benevolent figure in their lives – a spouse, or grandfather, or mentor – to explain how they feel and to imagine what this person would say in response.

“What is really healing,” Amidon said, “is to hear, whether it’s in this imagined conversation or with the others, someone sharing really shameful experiences and having people accept them – saying, ‘Yeah, that was fucked up, what you did, and remember all the good things you’ve done. This doesn’t have to define the rest of your life.’”

One participant, now 33, struggles with the guilt of having killed the wrong person. “My big thing was taking another man’s life and finding out later on that wasn’t who you were supposed to shoot,” he told me, asking not to be identified because of his continuing psychological treatment. “The [troops] out there, they don’t talk about it. They act like it never happened. Completely don’t ever bring it up.”

But in the San Diego moral injury program, he did summon the courage to stand up and talk about it. “Just saying it was helpful,” he said later. “There were about five people in the room, and they got it. I didn’t need to have anyone say it’s OK, because it’s not OK – that would have just pissed me off.”

What was the response of his peers? “It was silence,” he said. “That unsaid, ‘I don’t care what you did, we are still good.’

“People give you space. And they got a therapy dog in there, and he comes over and wags his tail a little bit, tells you it’s OK, too, you know? Not saying it’s OK, but just to say you’re not some wicked person.”

Felipe Tremillo, the Marine staff sergeant, took part in the San Diego program last fall. One assignment was to write an imaginary letter of apology. His was intended for a young Afghan boy whom he had glimpsed during a raid in which Marines busted down doors and ejected people from their homes while they searched inside for weapons. The boy had stood trembling as Tremillo and the Marines rifled through the family possessions, his eyes, Tremillo felt, blazing shame and rage.

“I didn’t know his name,” Tremillo said. But in his letter, “I told him how sorry I was at how I affected his life, that he didn’t have a fair chance to have a happy life, based off of our actions as a unit.” Writing the letter, he said, “wasn’t about me forgiving myself, more about accepting who I am now.”

Former Navy psychiatrist William P. Nash takes a slightly different approach in the experimental sessions he runs. His pioneering work with moral injury grew out of his experience as a combat therapist deployed with Marines in Iraq. Nash has developed a Moral Injury Events Scale, a self-evaluation for troops that asks them to respond to statements such as “I saw things that were morally wrong,” or “I am troubled by having acted in ways that violated my own morals or values,” or “I feel betrayed by leaders I once trusted.”

But from there, drawing out the painful, detailed explanations can be difficult.

“When they come in for treatment, the first thing out of their mouth is not, ‘I did something unforgivable and I want to tell you about it.’ Because they are working as hard as they can not to think about it,” Nash said. “They don’t know that you are not going to judge them. They may be on their last little thread of self-acceptance and they don’t want you to cut the thread.”

To reach them, Litz, Nash and others who have tried this approach to moral injury use a technique they call adaptive disclosure. In this therapy, patients are asked to briefly discuss what caused their moral injury. Among combat Marines, often the cause is the discovery that they love the thrill of combat and killing, followed by guilt for feeling that way, Nash said.

As in the San Diego program, patients are asked to imagine they are revealing their secret to a compassionate, trusted moral authority – a coach or priest. “The assumption here is if there is someone in your life who has your back, cares for you, is compassionate and you have felt their love for you, then you are safe in disclosing what you did or failed to do,” Litz explained. “If there is that compassionate love, that forgiving presence, it will kick-start thinking about, well, how do you fix this, how can you lead a good life now?” And that, he said, “is the beginning of self-compassion.”

The adaptive part of the therapy involves helping the patient accept his or her past actions. Yeah, I did this, or I saw this, or this really happened – but it’s not all my fault and I can live with it. Patients are asked to make a list of everyone, every person and institution, that bears some responsibility for their moral injury. They then assign each a percentage of blame, to add up to 100 percent. If a Marine shot a child in combat, he might accept 30 percent of the blame. He might award the Taliban 50 percent, the child himself 5 percent and the Marine Corps 5 percent. God, perhaps, 10 percent.

A variant of adaptive disclosure was used in experimental treatment led by Litz and Maria Steenkamp, a clinical research psychologist at the Boston VA medical center, working with Marines from Camp Pendleton, Calif.

After having patients describe in painful detail what caused their moral injury, therapists asked them to choose someone they saw as a compassionate moral authority and hold an imaginary conversation with that person, describing what happened and the shame they feel. They were then asked to verbalize the response, using their imagination. Inevitably, patients imagined being told they were a good person at heart, that they were forgiven, and that they could go on to lead a good life. Of course, these conversations rely on imagination. But the technique allows the patient to articulate in his or her own words an alternative narrative about his injury.

All these approaches are designed as quick interventions, specifically intended for combat troops who may be deployed again soon. The goal is to provide patients with insights and techniques to continue the work on their own – and eventually to move beyond their injury.

Left alone, Nash said, veterans with moral injury either conclude that “none of this is my fault,” or “it’s all my fault.” Neither can be totally true.

“In your heart of hearts, you know you were the one who pulled the trigger. You can’t unring the bell, can’t undo what was done. And that’s a time bomb,” he said. But when patients are helped to recognize their true share of the blame, “you can begin to make amends, until you get to a point where you can forgive, and that’s the ultimate challenge.”

“We don’t try to dispute, minimize or explain away” a morally questionable action. “We try to help the person understand that this action or inaction need not be destiny.” Matt J. Gray, psychologist

“To be clear, what we don’t do is to impose our moral appraisals or judgments [on] the situation, though we may occasionally have them,” Matt J. Gray, a University of Wyoming psychologist, said in an email. Gray led a 2012 study on therapy for moral injury and traumatic loss among 44 Marines. “We don’t try to dispute, minimize or explain away” a morally questionable action, he said. “We try to help the person understand that this action or inaction need not be destiny.”

Does this method actually work? The results are promising but not conclusive, in part because the studies conducted so far were designed as intense, short-term interventions with troops preparing to go back to war. True healing of a moral injury seems to take time.

“I don’t think it ever happens in the therapy,” Nash said, “because I don’t think the therapy is ever long enough for that to happen. All we can do is plant seeds.” But, he added, “as far as I know that’s the only route to salvation, and it ain’t easy and it ain’t quick.”

That was the conclusion of Gray’s clinical research trial in which adaptive disclosure therapy was used with 44 active-duty combat Marines with PTSD and moral injury. In six 90-minute sessions, Gray found that the Marines experienced “substantive” improvement in their symptoms. So substantive, in fact, that the study has been expanded to a five-year randomized clinical trial.

But success requires a long-term commitment, Gray wrote in a paper about the project. The six sessions “represented the beginning of a process that the Marine would need to continue after the formal conclusion of the intervention.”

Billie Grimes-Watson’s experience in therapy, last spring in the San Diego moral injury/moral repair group, underscores how long it can take to heal moral injury. Like others, she found it difficult in those sessions to describe her deepest wounds.

“I have more than one moral injury and I used the easier one and not the bad ones that are really affecting me,” she said in December, eight months after she completed the program.

What she told the group was “my small one,” about the Iraqi kids who would flock around U.S. troops and vehicles on patrol, begging for candy and cigarettes. As 2003 wore on, many of the kids in Baghdad turned sour, throwing rocks at American troops. Some troops started throwing rocks back.

“You could actually see them get hit pretty hard,” she said. “It’s something I normally wouldn’t do, bullying kids – I have kids of my own, and I can’t even think of anyone hurting them like I did with those kids.”

In therapy, she said, “I explained how peer pressure kind of gets to you and you do things you shouldn’t have done and you try to forgive yourself for it. People gave me hugs, a lot of crying and discussion. But I still feel guilty and I haven’t forgiven myself for a lot of the things I did over there.”

Now she is back home at Schofield Barracks in Hawaii, awaiting her discharge from the Army after 13 years. She’s been diagnosed with PTSD and physical ailments, but it’s the moral injuries that are truly disabling.

“I have all this guilt inside me and I want to let it out but I can’t,” she said. “I want to tell my husband and family what’s going on, but I don’t. I just put on a happy face until I’m alone.”

She’s been seeing a therapist since she returned from San Diego last spring, but she has not been able to even hint at her deeper injuries. Instead, she said, “I’ve started going backwards again. All the emotions and nightmares are coming back. I had stopped drinking and now I’m drinking again, trying to hide it. I can’t sleep at night.”

Her PTSD makes her agitated around crowds; it makes her depressed and often angry. “But moral injury is the one that really gets you,” she said. “It’s hard to find yourself again, because you’re never going to be the same person. I am trying to figure out how to forgive myself for everything I did over there, and it’s hard to figure out.

“I’m messed up. I’m tired of just taking the pills.”

What is needed, she said, is many more programs like San Diego – and longer therapies that might enable her eventually to acknowledge what she called “the bad moral injuries that are really affecting me.”

“We are still having suicides by people who don’t tell anyone why they are hurting inside,” she said. “We are still at war.”

This is the third in a three-part series.