For some veterans, guilt and shame can linger years after combat — and it’s not PTSD.

Aaron Throckmorton decided to join the military the day the Twin Towers fell. A standout high school linebacker at Midland Lee (of Friday Night Lights fame), Throckmorton quit his team that very afternoon. He doubled up on his schoolwork so he could finish early and become a Marine. There were military men in his family. His grandfather served during the Korean War, and an uncle was a “river rat” in Vietnam. But Throckmorton didn’t know much about their experiences.

“I never really asked,” he told me. No, it wasn’t because of his family’s pedigree that he was enlisting. He had watched the second plane hit the towers and felt “it was my duty to go and take care of those who had done it.”

After boot camp and infantry school, Throckmorton was sent to Afghanistan, where, as far as he’s concerned, he did the world some good by killing “bad men.” But just before he left the service, he suffered a nervous breakdown. When he returned to civilian life in 2006, he started drinking heavily and getting into fights. So he chose jobs with limited responsibilities, hoping to be left alone and stay out of trouble. For a stretch, he worked at a Wal-Mart in Roanoke, north of Fort Worth, rounding up carts from the parking lot. One day he was pushing a line of carts when a man in a car told him to hurry up. The two exchanged threats, and Throckmorton ended up chasing the car around the lot until the man got out and Throckmorton “started beating on him.” He was promptly fired.

Throckmorton’s story might sound familiar. Many veterans suffer significant difficulties readjusting to civilian life. According to a study released in July by the Veterans Administration, 20 veterans commit suicide daily. And though veterans make up just 9 percent of the population, they account for almost 20 percent of all suicides. Rates of alcoholism, anger and some forms of violence are higher among veterans. But what makes Throckmorton’s struggles stand out is that his symptoms do not neatly fit the criteria for post-traumatic stress disorder. PTSD is a fear-based mental disorder characterized by nightmares, flashbacks and hypervigilance. But these weren’t troubling Throckmorton. Instead, he suffered from something experts now call moral injury.

Tall and muscular with close-cropped dark hair, Throckmorton met me one June morning at the offices of Brite Divinity School, which is affiliated with Texas Christian University, in Fort Worth. We talked in a conference room reserved for us by theologian Rita Nakashima Brock, the director of the Soul Repair Center at Brite, which is the only program in the United States dedicated to educating the public about moral injury. For the better part of a morning, Throckmorton recounted his war stories. He was amicable if occasionally intense, and spoke with energy and thoughtfulness. Our interview was interrupted twice — once when Brock stopped in to say hi, and once when Throckmorton’s emotions overwhelmed him.

It wasn’t combat that had sparked his troubles, he told me. He had taken part in several firefights and so had naturally worried about his safety, and he described the “gruesome” deaths of several Afghan policemen killed during these fights. What haunted Throckmorton about his time in the military was not what he did, but what he didn’t do. “I should have been there for them,” he said of Marines he trained who later died in Iraq. “I could have trained them better.”

“Most soldiers fight for the person next to them,” Brock told me later. “Witnessing fellow soldiers die is one cause of moral injury.” In 2012, prior to launching the center, Brock co-authored Soul Repair: Recovering from Moral Injury after War, and in the years since, she has become one of the most prolific speakers on the topic. While it was first identified in 2009 by psychiatrist Jonathan Shay, most experts agree that it’s as old as war itself. Moral injury has only recently been considered separate from PTSD, though the two often coexist. PTSD is about fear and personal safety; moral injury consists of the shame and guilt engendered by witnessing or displaying behavior antithetical to what the soldier considers moral. Treatments for PTSD typically do not work on moral injury because moral injury is not fear-based. While PTSD is a clinical diagnosis treated according to criteria prescribed by the American Psychiatric Association, no diagnosis yet exists for moral injury.

The causes of moral injury are many. For example, it can stem from a soldier’s belief, as with Throckmorton, that he failed at what he viewed as his primary duty: protecting his troops. It has also been identified in soldiers who have killed civilians and tortured prisoners, but also in more blameless cases, such as handling human remains and guarding prisoners.

Another veteran I spoke to in Fort Worth, Michael Killam, was profoundly scarred by the combat he saw as a helicopter gunner in Vietnam. Sixty-five and lean, with long gray hair held back by an American flag bandana, Killam was anxious during our talk: He insisted the door to the conference room remain open, and his narrative was peppered with nervous laughter. A recovering alcoholic and heroin addict, Killam recounted an almost stereotypically horrible stint in Vietnam. His most heartrending tale occurred in 1969, when his helicopter was called to the site of a mortared orphanage. He and his crew were asked to find survivors. Killam says he stumbled upon a baby with a piece of shrapnel stuck in its chest. When he pulled it out, the baby bled to death, he remembers.

The memory still pains him. “Sometimes I feel like I left my soul over there,” he told me several times. His return from combat only aggravated his guilt. “When I got off the plane and was walking across the tarmac, a woman in the crowd called me a baby killer,” he said. “How did she know? I couldn’t understand how she knew.”

What many civilians don’t realize, Throckmorton emphasized, is that the stress of combat can be exacerbated by problems back home. Throckmorton’s personal life fell apart while he was in Afghanistan: His wife cheated on him and stopped paying the bills, ruining his credit. His grandfather, who had raised him and was his strongest male role model (Throckmorton never knew his father), died. These tragedies fostered a sense that his soldiers were his true family, compounding the heartache whenever any of them died.

“One night I was like, screw it, I’m suffering every day,” he said. “All this stuff is running through my head. So I went behind the barracks and tried to slit my wrists.” Luckily he was spotted before he could finish. “Sometimes I feel like I left my soul over there.” Though the Soul Repair Center doesn’t offer therapy services directly, Throckmorton and Killam have formed valuable relationships through the center’s network. Throckmorton met Col. J. Craig Combs, a retired Army chaplain who served in Iraq in 2005 and 2011. Now the faith-based community liaison for the Texas Veterans Commission, Combs was recruited by Brock to incorporate moral injury education into his veteran peer-support work. Brock said the center’s mission is to educate the public about moral injury, with a special emphasis on reaching clergy, VA professionals, veterans and their families. She made it clear that the center doesn’t provide treatment, partly because she doesn’t regard moral injury as an illness or disorder.

“We are working to disrupt the idea that moral injury is a disorder,” Brock said. “We regard it as a normal response to extremity.” She added that treatment can indeed help but it is not “a complete recovery process, rather an intervention that can begin a process. We try to teach people how to support the long process of recovery.”

It’s important, she said, for veterans to have an ongoing dialog with a “benevolent moral authority.” The sufferer often needs to feel forgiven, so a spiritual connection, as well as supportive friends and family, can be crucial. No standard therapy or recovery program yet exists, but clinical trials of a technique called Adaptive Disclosure, which incorporates blame dispersion and role-play scenarios with imagined authority figures, are currently underway. (Clinical psychologist Brett Litz, who pioneered Adaptive Disclosure, told me that results from one of the trials will be released next year.)

The Soul Repair Center has its roots in peace activism. In 2008, Brock and Gabriella Lettini organized the Truth Commission on Conscience and War to examine the consequences to soldiers fighting the wars in Iraq and Afghanistan. As they wrote in Soul Repair, a key goal was to help the public “understand society’s responsibility for them and how soldiers struggle with conscience in war.” Out of the commission emerged two resolutions: The United States should recognize “selective” Conscientious Objector status for those who espouse just-war principles, not pacifism; and moral injury needed to be understood as a key driver of veteran suffering. Brock stressed that she does not promote a political or military agenda in her education about moral injury.

Both Killam and Throckmorton struggled for years with the standard treatment options for vets. After his breakdown, Throckmorton said, he was put in a room with doctors “who were, like, colonels,” and they demanded to know what his problem was. “It was the most uncomfortable thing in the world,” he said. “I felt like a new college student being thrown in front of the dean. I couldn’t talk to them.”

Once out, Throckmorton went to the Fort Worth VA, which he said was “hell.” Treated rudely and shuffled frequently between the Dallas and Fort Worth centers, he quit in frustration. Afterward, he fell into a pattern of “doing good for a while, doing bad, doing good, doing bad,” all while “drowning myself in guilt and alcohol.”

It wasn’t until each man identified his moral injury (Killam also suffers from PTSD and traumatic brain injury), found the proper mentor, and began helping other veterans that the recovery process began in earnest. A breakthrough for Killam occurred when one of Brock’s colleagues suggested he view his key moral wound differently: Maybe the baby was going to die anyway, and Killam was able to offer a loving embrace in its last moments of life. “That was such an amazing, loving way to think of it,” Killam said. “I’d never thought of that. Maybe that’s what the whole thing was about.”

In 2008, Killam obtained his certificate in drug and alcohol counseling and has become a program manager of veteran services at Mental Health and Mental Retardation (MHMR) of Tarrant County. In addition to working with Brock and the Soul Repair Center, Killam is a peer coordinator with Texas’ Military Veteran Peer Network.

In 2013, Throckmorton founded a nonprofit CrossFit competition for veterans called the Agoge Challenge. During annual competitions, Throckmorton’s crew sets up veteran resource booths and holds job fairs. “All the things I didn’t have when I got out, I made sure to put it in one competition,” he said. “As much bad as there is in this world, I’m going to do everything I can to bring good to it.”

Before we shook hands goodbye, Throckmorton handed me a promotional DVD of the challenge. His dark eyes were sharp and determined. “As a Marine you’re not supposed to offer a bunch of complaints without a solution,” he said. “That’s the number-one thing I was taught. So that’s what I did.”

[Featured image of Aaron Throckmorton by Sebron Snyder]