The spiritual injury assessment or Berg Spiritual Injury Scale (SIS) measures moral and spiritual injury severity. Spiritual injury and moral injury are related concepts but have distinct meanings and origins. A spiritual injury is a deep emotional or psychological wound affecting a person's spiritual well-being, sense of meaning, purpose, or connection with a higher power or God. It is our response to an event we cause or an event beyond our control that damages our relationship with God, self, and others and alienates us from what gives meaning to our lives. Rather than the dyad of self and others as in a moral injury, spiritual injury incorporates the eternal Thou or God in a triad. From this perspective, a higher power or the Divine is crucial in treating others and us. It is a trinity of God, self, and another. It harms us spiritually by damaging the soul. It severs or hurts our relationship with God and with others.
Morality and moral injury pertain to the relationship between humans to humans. Belief in God is not a requirement for us to be ethical. Emanual Kant's "categorical imperative" is a moral principle that signifies that we should act a certain way only if we are willing to have everyone else behave similarly. It is similar to the Golden Rule, which posits that I act toward others in ways I would want everyone else to behave toward me.
Whatever one's moral philosophy, moral injury occurs when we act in ways or are required to act in ways that are contrary to our deeply held values and beliefs. Morality has to do with how we behave towards others, with a focus on the bio-psycho-social dimension of human behavior. On the other hand, a spiritual injury includes a personal, interpersonal, and moral dimension, including beliefs, values, and our relationship with the divine or transcendent. An essential element is the sacred aspect of human activity and faith.
While there is an overlap between spiritual and moral injury, the key distinction lies in their origins. Spiritual injury primarily focuses on disruptions in the realm of spirituality, meaning, and existential beliefs, while moral injury relates to the violation of deeply held moral values and ethical standards. Symptoms and feelings elicited by both wounds also overlap. They include the eight characteristics listed below. These eight injuries frequently appeared in my counseling with combat veterans and the research we conducted at the Department of Veterans Affairs Medical Center in Saint Cloud, Minnesota. The literature and books written by and about combat soldiers also reflect these responses. They are especially characteristic of those with post-traumatic stress disorder or chemical dependency.
In addressing the issue of guilt, I will use as a case study the guilt suffered by many veterans, particularly those who faced combat in Vietnam. There are two reasons for this choice. First, much of the background for developing the SIS originated in work done in a VA Medical Center with many veterans who served in Vietnam. Nearly 4,000 veterans who have completed this inventory identify guilt as the number one spiritual injury they struggle with. Secondly, if we can understand guilt in the chaotic evilness of war, we can more easily understand and address lesser expressions of its injury in therapy. In tackling a worst-case scenario, the more ordinary examples we experience daily will not be so bewildering. The difficulty in this approach is that we can too quickly distance ourselves from war if we have not experienced it and fail to identify with the spiritual pain felt by those who understand how persistent and destructive guilt caused by war can be.
The Saint Cloud VA conducted an active alcohol and chemical dependency unit while I served there as a chaplain. Recovery centered on a 12 Step model championed by Alcoholics Anonymous and the Hazelden Treatment Center in Minnesota. Veterans who completed the program were required to complete a 4th Step which included a "searching and fearless moral inventory," followed by a 5th Step admitting to "God, to oneself, and to another human being the exact nature of their wrongs." Typically veterans shared these confidential inventories with a chaplain. The moral injury of guilt was high on the "character defects" list shared with us.
In writing about healing from the trauma of war, combat veteran Arthur Egendorf defines guilt as "a catch-all term for the feeling that emerges from our belief that by virtue of something we've seen, done, or lent support to, we are unworthy or unclean."These feelings were frequent in what was relayed to me by veterans of the Vietnam War.
William Mahedy, a chaplain in Vietnam and authority on PTSD and its treatment, has written persuasively about soldiers' guilt:
Among the painful legacies of Vietnam—loss of religious faith, rage directed against God, fundamental moral questions unresolved, pervasive cynicism—one, in particular, is found in almost all the stories: guilt.
Guilt has a bad name in our society. It is usually associated with unwanted and unpleasant feelings and anxieties arising from our inability to cope with our own drives and ambitions. We deal with guilt by assuring ourselves—often through some form of therapy—that guilt is an inappropriate feeling, a harmful by-product of a "punitive superego." To deal with guilt, we simply convince ourselves that we're "okay" people and then go about the business of living. But guilt reaches more deeply into the human soul than our society is willing to admit. Guilt sometimes arises from our awareness that we have, in fact, participated in evil, that we have violated our conscience, and acted against moral standards we had previously accepted as valid.
In "Living with Moral Pain," an article published in Psychology Today, Peter Marin states that the unacknowledged source of much of the veterans' pain and anger is a profound moral distress, one that arises from the realization that one has committed acts that have real and terrible consequences. Prevailing cultural wisdom, models of human nature, and modes of therapy are inadequate to explain moral pain or provide ways of dealing with it.
As a VA chaplain assessing the spiritual needs of veterans, I observed this to be true. I identify this moral pain with deep guilt based on the behaviors and actions of those returning from wars. I observed veterans being judged harshly by other therapists for expressing guilt as though it was merely a feeling with no physical, objective, or factual basis. Events and actions that are the source of guilt can be life-changing, damaging the soul and sense of self. After experiencing the trauma of war, killing other human beings, and engaging in the violence inherent in combat, a human being is changed forever. When visiting the World War II museum in New Orleans, a quotation by Richard Proulx, Infantryman, US Army, caught my attention and witnessed this reality: "One cannot go to war and come back normal."
Traditional psychotherapeutic methods do not deal with moral and spiritual injuries of the soul. Martin Buber observed that the boundaries set by psychotherapy do not explain the negative or indifferent attitude most psychotherapists take toward the reality of guilt.Sigmund Freud concluded that guilt feelings were a projection of communal and parental taboos on the superego; as such, they were imaginary and had no factual basis. Carl Jung did not address guilt directly as a subject for therapy. Still, he included it as part of the "shadow" or dark side of one's personality, along with feelings of inferiority, self-hate, and aggression. According to Jung, the individuation process involves identifying evil as part of the opposites in the psyche and part of the self. Buber says Jung's work offers no help in understanding guilt as a natural reaction to painful and difficult experiences one might encounter in our relationships with others.
Psychiatry briefly addressed guilt in its Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition (DSM-3), published in 1980, as a symptom of PTSD. It only refers to "survivor guilt." Guilt based on one's behavior is not mentioned. Survivor guilt arises when people have been exposed to or witnessed someone else's death yet stayed alive themselves. Combat survivors often feel responsible for the death or injury of others, even when they have no real power or control over the situation. DSM-4 (2000) listed survivor guilt as an associated symptom of PTSD, but DSM-5 (2013) eliminated survivor guilt as a symptom of PTSD altogether. What the manual refers to as "subjective responses to trauma exposure" has been removed as a criterion of PTSD. This definition would include those conditions associated with moral and spiritual injury.
This lack of understanding by traditional psychotherapeutic methods to uncover the nature and origin of guilt does no more than hide or camouflage the deep pain and hurts that soldiers bring back from war. Biochemical remedies, though sometimes helpful, merely mask the symptoms of PTSD; talk therapies such as cognitive behavioral therapy are future-oriented and behavioral specific; they fail to address the existential nature of spiritual and moral injuries suffered by soldiers of war.
Therefore, Science and medicine do not have answers for moral and spiritual injuries such as guilt that present themselves to the therapist treating war veterans. Psychiatry redefines spiritual and moral injuries as anxiety or "trauma and stressor-related disorders."The spiritual and ethical nature of war, which is the heart of the matter, is never addressed. If an existential issue such as guilt has no psychopharmacological remedy, it is written out of scientific medicine's playbook.
Our faith communities and religion, at their best, have taken responsibility for healing spiritual injuries. The healing rituals practiced by churches, mosques, and temples include repentance, confession, absolution, forgiveness, penance, and atonement. Combat veteran Arthur Egendorf, in Healing From the War: Trauma & Transformation After Vietnam, writes: "I was struck by the power of forgiveness: Whenever forgiveness is granted, it overrules logic and flies in the face of countless reasons against it."He continues,
None of the psychotherapists I knew raised the possibility of forgiveness with their patients…. Nothing in the repertoire of psychological techniques and philosophical arguments I knew came close to the power of forgiveness. Only "I forgive you" has the potency to put an end to the recriminations and self-recriminations once and for all.
Then he offers us a cautionary tale. "But what in us has the right to forgive? What in us has the power to shift so profoundly our relationship with the facts of what we've lived through? I couldn't answer. The question pointed to impossibility: Only a saint or a megalomaniac could forgive the kind of horrors I knew."
I do not know, either. As a nation and culture, forgiveness will only be complete when war is made obsolete. And that will only happen when governments unite as a global community and outlaw it.
Arthur Egendorf, Healing From The War: Trauma and Transformation After Vietnam (Boston: Houghton Mifflin Company, 1985), 124.
William P. Mahedy, Out of the Night: The Spiritual Journey of Vietnam Vets (New York: Ballantine Books, 1986), 9.
Peter Marin, “Living with Moral Pain,” Psychology Today (November 1981), 68.
Martin Buber, The Knowledge of Man: A Philosophy of the Interhuman (New York: Harper & Row, Publishers, 1965), 123.
 Ibid., 126.
 Arthur Egendorf, Healing From the War: Trauma and Transformation After Vietnam (Boston: Houghton Mifflin Company, 1985), 186.
A second spiritual injury evident in combat veterans is anger. It is related to the issue of guilt. Anger and guilt are highly correlated. Angry because their government sent them to commit such foul acts against humanity and because expressing their anger may later lead to behaviors that cause additional guilt and remorse.
Anger is essential to war and killing. We dehumanize our enemies to justify our attitudes and violent behavior. They all become gooks or ragheads; in other words, anything that is offensive and derogatory. If we saw the enemy as "poor sods just like me," as Paul Baumer does in All Quiet on the Western Front, killing would not be so easy.
Each side terrorizes the other, providing ample evidence to justify an "eye for an eye, tooth for a tooth" behavior. The lust for revenge becomes a motivator, especially when morale is low, and soldiers feel their leaders have betrayed them. Both sides commit murder and other atrocities, and terrorism. A program in Vietnam that allowed for such atrocities was named Phoenix. It was a counterinsurgency program to identify and neutralize the infrastructure supporting the National Liberation Front insurgency in South Vietnam. Thousands of individuals were estimated to be captured or killed during its implementation. One veteran describing the Phoenix program explained, "If I live to be five hundred years old, I can never atone for what I did in Vietnam."
Jonathon Shay defines moral injury as a betrayal of what is morally right by someone who holds legitimate authority in a high-stakes situation. In counseling sessions, I often found more anger expressed toward military leaders than towards enemy soldiers they were ordered to kill. This anger was expressed in soldiers refusing to follow orders. In extreme cases, military officers were "fragged" or killed by a soldier under their command.
Spiritually, veterans directed their anger toward God. When vets ask, "Where was God in Vietnam, Afghanistan, or Iraq?" it is often an expression of rage toward God. In recent US wars, now judged as catastrophic failures, veterans answer the God question by concluding that God was AWOL. When spiritual support was most needed, it was absent. When prayers for victory, protection, and safety went unanswered, soldiers steeped in religion ingrained with the commandment "Thou shalt not kill" found the juxtaposition between what they were doing and what they had been taught to do too much to bear. Religious faith and trust in a just and loving God is another casualty of war.
During the 1960s and the 1970s, anti-war songs often expressed this anger. Bob Dylan's Blowin' in the Wind, Bruce Springsteen's Born in the USA, Pete Seeger's Waste Deep in the Big Muddy, John Prine's mournful song Sam Stone, and many others express this anger.
Unfortunately, anger does not go away when wars end. Veteran Mark Baker, in Nam, writes:
I keep thinking I'm past that now. I'm on top of that. I'm in control and there's no reason for the anger anymore. I'm over being mad. But I'm not. I'm not. Anger is part of me now. I'm going to go through my whole life dealing with my anger. It's going to come back at me time and time again in one form or another.
After coming home from the Vietnam War, a soldier I counseled turned his anger towards God by entering the cathedral where he had previously worshipped and smashed the sanctuary items and metalware on the church's altar.
Mahedy, Ibid., 20.
Mark Baker, Nam: The Vietnam War in the Words of the Men and Women Who Fousght There (New York: William Morrow and Company, Inc., 1981), 299.
Understandably, killing and war create profound grief and sadness, perhaps partly as a loss of innocence. Sometimes remorse is too great to bear, leading to suicide. Research conducted by the Chaplain Service at the VA Medical Center in Saint Cloud showed a high correlation between grief, PTSD, and depression. In addition to the loss of innocence and a moral compass, our spiritual assessments reported significant losses, including divorce, frequent job losses, family conflict, financial distress, and alcohol and drug abuse. All of these create further grief and remorse.
In times of war, soldiers live with the losses and deaths of friends. Often, they do not have time to grieve, or there is so much death that they are overwhelmed and unable to tend to their grief. A frequent response to soldiers' losses was, "It don't mean nothin'." Grief was delayed, or it never got expressed. Soldiers killed in war were often referred to as "wasted" by fellow soldiers. But when they fill out spiritual assessments, they answer that they "often" or "very often" feel grief and sadness.
Mark Baker tells of one soldier from the Vietnam War who said he never cried during his active duty in the military. Then "I woke up April 6, 1970, in tears and cried all day. I cried from 8:30 in the morning until five o'clock in the afternoon—pretty much nonstop. Perhaps three hours of that were hysterical uncontrolled crying. I was crying for everything." These may be fortunate to have an outlet for their grief finally! Grief therapy groups were one of the tools chaplains used at the Saint Cloud VA to address these losses.
Stephen Klinkhammer, who served as a Navy Hospital Corpsman during the Vietnam War, writes:
I have cried my ass off. I don't have tears left. . . I wake up with bad dreams that I have of taking fire and watching people being murdered and being a part of that process. . . I have to cry a lot and talk. . . There is no understanding. My mind isn't mature enough. It wasn't then and it isn't now and it's never going to be able to understand murder.
War is sin. War is murder.
Gary E. Berg, “The Relationship between Spiritual Distress, PTSD and Depression,” Journal of Pastoral Care & Counseling65, no. 1 (2011) p. 4.
Mark Baker, NAM: The Vietnam War in the Wosrds of the Men and Women Who Fought There (New York: William Morrow and Company, Inc., 1981), 297.
Al Santoli, Everything We Had: an Oral History of the Vietnam War by Thirty-three American Soldiers Who Fought It (New York: Ballantine Books, 1981), 259.
The importance of meaning and purpose in a person's life, and the destruction it causes when missing, was apparent in research conducted with Vietnam veterans in Saint Cloud, Minnesota.The all-too-familiar phrase of veterans returning from combat that "it don't mean nothin'" should be a giveaway that it means everything. The title of Al Santoli's oral history of the Vietnam War, Everything We Had, captures this sense of meaning. "Don't mean nothin'" becomes part of the denial system and psychological numbing that are characteristic of PTSD.
Theologian Douglas John Hall writes that the dominant anxiety of modernity is meaninglessness and despair, not guilt and condemnation. "A theology which offers tried and true remedies for the human anxiety of guilt and condemnation when the regnant anxiety is the anxiety of meaninglessness and despair is not theology."Hall later writes:
Undoubtedly, guilt and fear are still aspects of contemporary life in North America, for they seem to belong to the human condition; but they are certainly not our primary anxiety. None of the "signs of the times," whether our art, our social sciences, or our popular pastimes, betrays a people consumed by their guilt before God and the prospect of eternal damnation. Everything points to a different anxiety type, and, however it may be terminologically designated, it is certainly closer to what Tillich called "the anxiety of meaninglessness and despair" than to existential guilt before the eternal. We are not so much afraid that we do not measure up to a transcendent canon of human righteousness as that there are no transcendent standards of goodness, beauty, or truth beyond our own lingering desire that such standards might exist.
During World War II, psychiatrist Victor Frankl spent three grim years at Auschwitz and other Nazi prisons. At the war's end, he writes about those who survived and those who did not. Finding meaning and purpose in their lives despite or during their suffering helped prisoners survive. He quotes Nietzsche, "He who has a why to live for can bear almost any how." Frankl's psychotherapy which he developed and labeled logotherapy focused on a search for meaning and purpose in life.
In contrast to Freudian psychoanalysis, centered on a will to pleasure, or Adlerian's emphasis on a will to power, logotherapy speaks of one's primary motivational force as being a will to meaning. We live because of our ideals and values. Logotherapy places responsibility for identifying what gives life meaning to the individual, not the therapist. Logotherapy also emphasizes that those ideals and values transcend self-centeredness and connecting with something larger than oneself. It includes community and the importance of love.
In writing about a hierarchy of human needs, like Frankl, Abraham Maslow identified self-actualization as our highest need. Self-actualization only comes after our physiological well-being, safety, belonging and love, and esteem needs have been met. Before his death, Maslow spoke of a still higher need: to see beyond our well-being to the needs of us all. He identified it as the need to transcend ourselves. This self-transcendence, he says, gives us a sense of meaning and purpose in life that is greater than the self.
In a study of 89 Vietnam veterans conducted at the VA Medical Center in Saint Cloud, veterans identified the absence of meaning and purpose in life as the spiritual injury most highly correlated with PTSD and thoughts of suicide.
Al Santoli, Everything We Had (New York: Ballan tine Books, 1981).
Douglas John Hall, Thinking the Faith: Christian Theology in a North American Context (Minneapolis: Augsburg, 1989), 92.
Hall, Ibid., 98.
Victor Frankl, Man’s Search for Meaning: an introduction to logotherapy(New York: Pocket Book, 1973), 121.
A spiritual injury related to a lack of meaning and purpose is despair or hopelessness. The origin and meaning of the word despair is to be without hope. In writing about despair, Paul Tillich states, "Despair is an ultimate 'boundary-line' situation. One cannot go beyond it."Yet, in war, soldiers always cross the boundary lines established by morality and religious faith.
Philosopher Soren Kierkegaard speaks of despair as the feeling we have when we are the person we do not want to be or are sick of ourselves. Related to moral and spiritual injury, this means being the person we do not want to be because of what we have done. Vietnam War chaplain William Mahedy addresses the issue from the vantage point of Vietnam veterans--young men and women whose average age was slightly over nineteen. He writes: "Their religious and moral experience amounted to an unprecedented and totally unexpected deadening of the soul. The spirit went numb…. A terrible bleakness had overwhelmed the soul…. For great numbers of veterans, duty in Vietnam was a journey into spiritual darkness—the very darkest night of the soul."A war crosses over many boundaries. There was no going back.
The word despair frequently reoccurs in the accounts of moral injury. Jonathon Shay describes despair as "this word that's so hard to get our arms around…. It's despair that rips people apart [who] feel they've become irredeemable."
Charles Pacello, an Air Force officer assigned to a unit responsible for managing nuclear weapons, writes, "Moral Injury is a crisis within the soul, the seat of our conscience, wounding our hearts and severing our bonds with others and with the Divine."It is not only those who actively kill who bear the wounds of moral injury. He explains:
In the core of my being, I felt as if my soul had been pierced through, and I thought to myself, as I looked around in terror and rage at what I was contributing to, This is not what I signed up for. I wanted to preserve, protect, and defend our nation. Not participate in the planning for the destruction and annihilation of mankind.
Even those who plan and train for war can bear the disabling anguish, shame, and despair of spiritual injury. Pacello lost his moral compass, his soul revolted, and life lost all meaning and purpose. He also lost family, friends, and belief in a loving God. His "dark night of his soul" became filled with drugs and alcohol, chronic depression, and suicidal contemplation. Unlike many war veterans, Pacello was able to rally. "Something inside me said, 'You've got to keep going, you can do it, you can face what needs to be faced.'"
Douglas John Hall echoes similar thoughts in a section of his theology titled, God lives, life goes on!He quotes at length from Samuel Beckett's The Unnameable. Hall states that the street metaphor "going on" speaks to contemporary forms of human anxiety and alienation:
In distinction from our 19th-century forebears, whose attitude towards life and the future enabled them to lace their rhetoric with terms like "challenge" and "adventure" and to name little towns on the western frontier of this great continent "Onward" and "Success" and the like, late 20th century homo sapiens ask whether it is possible to…" go on." Samuel Beckett's concluding lines in The Unnameable capture the mood of our epoch with characteristic sensitivity: "You must go on, I can't go on, you must go on, I'll go on…." It is this form of human experience with which, in the First World at least, Christian theology today must wrestle. The gospel must be expressed in such a way as to speak to this sense of psychic impasse, which today is as fully public as it is private.
Paul Tillich, The Courage To Be (New Haven & London: Yale University Press, 1952), 54.
Howard V. Hong and Edna H. Hong, eds., The Essential Kierkegaard(Princeton, New Jersey: Princeton University Press, 1978), 356.
Robert Emmet Meagher and Douglas A. Pryer, editors, War and Moral Injury: A Reader (Eugene, Oregon: Cascade Books, 2018), 92.
 Ibid., 116.
 Ibid., 115.
 Ibid., 118.
Hall, Ibid., 103.
The source of much anger that combat veterans feel is the perception that life has not been fair to them. This sense of betrayal is reflected in Harold Kushner's popular book When Bad Things Happen to Good People. Veterans I counseled wanted to know, "Why me? What have I done to deserve this?" Ultimately the question is addressed to God. It focuses on Divine justice and probes the depths of faith amid suffering. Is this a just or an unjust universe? Do things happen randomly, fatalistically, intentionally, or accidentally? Attitudes of cynicism, hope, despair, fatalism, and gratitude reflect how this question gets answered and worked out daily.
Veterans of the Vietnam War whom I counseled had ample reasons to question life's fairness. For the most part, at that time, young men did not enlist in the military but were drafted. The method that consigned them to military service was a lottery system. The first lottery drawing since 1942 was conducted on December 1, 1969. The event determined the call order for induction during 1970 and included all men born between January 1, 1944, and December 31, 1950. Certain deferments were available based on medical reasons, marital status, and enrollment in college. The system seemed arbitrary and unfair for those unable to avoid the draft. And it was.
Uwe Siemon-Netto was a chaplain intern at the Veterans Administration Medical Center in Saint Cloud, Minnesota. In his book, The Acquittal of God: A Theology for Vietnam Veterans, he writes of "the country which had sent them out to die then rejected them when they returned with wounded souls and bodies."Nothing hurt Vietnam veterans so much as to be spit upon and called "baby killers" when they returned home after risking their lives and being required to kill people and destroy another country's culture and countryside—all in service to their own country. These events—being "in country", killing, and coming home—weighed heavily on the consciences of many veterans.
Theologically, the problem of evil is addressed as theodicy, which is the philosophical or theological attempt to reconcile the existence of evil or suffering in the world with a belief in God. How can a loving God permit the enormous evil present in our world? It gave veterans a reason to ask, "Where was God in Vietnam?" The conclusion many reached was God was AWOL (Absent Without Leave) and had abandoned them. Soldiers who arrived in Vietnam with a devout faith soon had it stripped away by the evil that engulfed them. Many veterans never regained the religious belief they once had.
Uwe Siemon-Netto, The Acquittal of God: A Theology for Vietnam Veterans(New York: Pilgrim Press, 1990), 11.
In theological terms, war correspondent Uwe Siemon-Netto, who received his clinical training in the Chaplain Service at Saint Cloud, writes, "War is sin because it is a form of hatred for one's fellow human beings. It results in nihilism and ultimately represents a turning away from God."It attacks and damages the soul, bringing with it rage toward God. William Mahedy describes the veterans he counseled:
They often call God obscene names—bastard, motherf….r, son of a bitch--because they are convinced that He failed them in their moment of greatest need. Our teenaged soldiers of the sixties and seventies, like most Americans, had been led to believe that God would never let them down, that He would always lead them to victory over evil and preserve them in battle against the foe. In Vietnam, it didn't turn out that way. There, young men discovered they'd 'been had,' and they feel terribly betrayed to this day.
Research conducted by the VA Chaplain Service in Saint Cloud indicates that Vietnam veterans were less religious than older veterans who had served during earlier periods in our nation's history. Our research also revealed that veterans who maintained a religious faith and were engaged in a spiritual community after they returned home experienced fewer symptoms of PTSD and depression than veterans without this support system.
A century earlier, Freudian psychoanalytic theory hypothesized that the repression of sexuality and a harsh superego was the cause of neurosis. Today, the fastest growing denomination in America is "nones," or those having no religious faith. Repression today is more likely to be a repression of belief in God or a Higher Power. The existential vacuum created by the absence of a safe harbor or foundational beliefs offered by the rituals of religious faith and practice left many young men returning from war adrift with no chart or compass to direct them. Our research indicated that it expressed itself in high levels of depression, drug and alcohol addiction, and a higher level of suicidal behavior than experienced by their cohorts. Our findings also indicate a strong inverse relationship between intrinsic religious faith and spiritual distress or injury.
 Ibid., 38.
Berg, Ibid., 8.
 Berg, Ibid., 6.
Ernest Becker writes that the fear of death—or the terror of death, as he calls it—is behind humans' anxiety and everyday functioning. He says we must repress this fear, or we cannot function. It is an invisible burden we carry around our necks. Research at the Saint Cloud VA Medical Center found that war veterans denied or minimized this fear. They ranked the spiritual injuries of guilt, despair, lack of meaning in life, and feeling God's abandonment much higher than their fear of death.Perhaps this is why former Governor and Senator Bob Kerrey could say killing for your country is much worse than dying for your country because it is a memory that lasts.
But the fear of living and the struggle to go on is an issue combat veterans with PTSD know well. The flashbacks, nightmares, startle responses, memories, and spiritual injuries correlate highly with suicidal behavior. Sixty-four percent of veterans in our study with PTSD indicated they had considered suicide in the past two years.In 2021, research found four times as many active-duty personnel and veterans have died by suicide (30,177) since 9/11, compared with those killed in combat (7,057) in those same 20 years.
Ernest Becker, The Denial of Death (New York: Free Press, 1973), 16.
Berg, Ibid., 4.
 Rachel M. MacNair, Perpetration-Induced Traumatic Stress: The Psychological Consequences of Killing (Westport, Connecticut, Praeger Publishers, 2002), Chapter 12, Kindle.
 Berg, Ibid.
The eight items on the Berg Spiritual Injury Scale are existential, philosophical, and religious states that are spiritual and moral injuries. They go beyond and are more profound than the bio-psycho-social conditions typically treated in a medical clinic or therapist's office. These spiritual conditions are absent or erased from diagnostic manuals and omitted from the therapies usually offered. Yet they are the existential burdens brought to our attention in our clinics, churches, and counseling offices. Until we address them, the persons we love and care for will continue to bear the invisible scars of spiritual and moral injury.
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