Moral Injury: Invisible Wounds of Combat

John E. Franklin, M.D., HMDC, FAAHPM

John Painter, M.Div., PhD

Ralph H. Johnson VA Medical Center

Charleston, South Carolina

John M. Schluep, D. Min. (Founder and CEO, Warriors’ Journey Home, Inc., Senior Pastor, First Congregational Church of Tallmadge, Ohio)

Disclosurse:

John Franklin and John Painter:

No relevant financial relationships to disclose.

John Schluep: Founder and CEO, Warriors’ Journey Home, Inc., author: “Souls Cry”, “Heart and Soul Liturgy”, and “Warrior’s Journey Home Facilitator Manual” from which he receives no financial remuneration.

Objectives

• Define moral injury and how it differs from PTSD.

• Discuss the causes and symptoms of moral injury

• Discuss treatment options for healing these invisible wounds of combat:

• Medical-Mental Health model

• The role of the Chaplain in treating wounds of the soul

• Spiritual/community healing

Why Me?

Why do I need to know about Moral Injury?

I don’t work at the VA.

“Thou shalt not kill.”

Moral Injury

• Not a new concept

• It has been present in soldiers and veterans going back to ancient Greece (battle fatigue, shell shock, inner conflict)

• New recognition, interest and research

• It is not a psychiatric or mental illness. No DSM-5 diagnostic criteria

• Not officially recognized by DOD or the VA. Does not qualify for VA disability compensation

• Not PTSD

Definitions• Jonathan Shay:

• “A betrayal of what's right by someone who holds legitimate authority in a high-stakes situation.“ [1] “The soul wound inflicted by doing what violates one’s own ethics, ideals, or attachments.” [2]

• Bret Litz:• “Perpetrating, failing to prevent, bearing witness to or learning about acts that

transgress deeply held moral beliefs and expectations.” [5]

• VA:• “An act of serious transgression that leads to serious inner conflict because the

experience is at odds with core ethical and moral beliefs…” [3]

• Rita Nakashima Brock and Gabriella Lettini:• “…souls in anguish, not a psychological disorder.” This occurs when veterans struggle

with a lost sense of humanity after transgressing deeply held moral beliefs. [6]

Definitions

• A syndrome of shame, self handicapping, anger, and demoralization that occurs when deeply held beliefs and expectations about moral and ethical conduct are transgressed. [7]

• Psychological injury which results from transgressions of deeply held moral and ethical beliefs and expectations. [8]

• A sense that their fundamental understanding of right and wrong has been violated, and the grief, numbness or guilt that often ensues. [9]

Examples of Events That Can Cause Moral Injury

http://youtu.be/aUOWZAXYhPs

Examples of Events That Can Cause Moral Injury

• Vietnam Combat Soldier

• Vietnam Combat Marine

• Marine Sniper in Fallujah

• Marine in Afghanistan

Examples of Events That Can Cause Moral Injury

• Killing the enemy

• Killing innocent women, children, elderly

• Collateral damage

• Friendly fire

• Not preventing/stopping atrocities

Moral Injury• Can emerge long after events or experiences

• Creates Isolation

• Can affect many professions (medical, protective services, social work, ministry)

• Family members and friends may also suffer from secondary moral injury and secondary trauma from the sharing of the Veteran’s story

Moral Injury

• ‘Veterans need to understand this guilt, shame, and depression are not because they are “bad” or “immoral” people, but specifically because they are so inherently good in a world that sometimes isn’t.’ [10]

• “Moral injury is a perfectly normal reaction to a perfectly abnormal situation.” [6]

Symptoms

• Guilt

• Shame

• Self-condemnation

• Demoralization

• Betrayal (leaders, self, peers)

• Self-handicapping behaviors (e.g., alcohol or drug use)

• Self-harm (e.g., suicidal ideation or attempt)

• Anger

• Outrage

• Grief

Symptoms

• Social problems

• Trust issues

• Spiritual/existential issues

• Psychological issues

• Embarrassment

• Humiliation

• Remorse

• Despair

Treatment

• Medical-mental health directed therapy

• Spiritually directed

• Spiritual/community healing

Medical/Mental Health Treatment Model

San Diego Naval Medical Center Moral Injury/

Moral Repair Program

Multidisciplinary and Group Therapy

Most effective treatment method

San Diego Naval Medical Center Moral Injury/Moral Repair Program

• Participants become comfortable with each other and develop trust before

• Sharing their story

• Participants provide non-judgmental support without excusing what was done

• Accept the wrong that was done

• Letter writing to self from a benevolent figure (or imaginary conversation with compassionate moral authority) to develop self-compassion

• Community service projects

• Random acts of kindness

• To feel acceptance back into the community

PTSD

• A psychiatric diagnosis with a DSM-5 code

• Has a mental health treatment model

• Recognized by DOD and VA

• Acceptable for VA disability compensation

PTSD

• PTSD and moral injury are often conflated. One can have PTSD without moral injury, and moral injury without PTSD. [10]

• Existing PTSD treatment frameworks may not sufficiently target moral injury. [5]

PTSD vs Moral Injury

http://projects.huffingtonpost.com/moral-injury/the-grunts

PTSD vs Moral Injury

• PTSD often experienced by Veterans who were the target of an attack or who were close to the target by proximity or through personal relationship

• Moral injury occurs when an individual experiences guilt, shame, and/or a feeling of betrayal following a transgression of their deeply held beliefs, which can result from actions taken or witnessed in combat. [11]

References

1. Jonathan Shay “Achilles in Vietnam: Combat Trauma and the undoing of Character.” New York: Athenaeum Imprint of Macmillan, 1998

2. Jonathan Shay, “Moral Injury” Intertexts, Vol 10, no. 1,2012, 58

3. VA PTSD Research Quarterly, Volume 23/#1

4. http://projects.huffingtonpost.com/moral-injury/the-grunts

5. B.T. Litz et al. “Moral injury and moral repair in war veterans: A preliminary model and intervention strategy.” Clinical Psychology Review 29 (2009) 695–706

6. Rita Nakashima and Gabriella Lettini, Soul Repair: Recovering from Moral Injury After War (Boston: Beacon Press, 2012).

7. Matt J. Gray et al. , Adaptive Disclosure: An Open Trial of a Novel Exposure-Based Intervention for Service Members With Combat-Related Psychological Stress Injuries. Behavior Therapy,43 (2012) 407-415.

8. Nash, W.P. & Litz, B.T. Moral Injury: A Mechanism for War-Related Psychological Trauma in Military Family Members Clin Child Fam Psychol Rev (2013) 16: 365. doi:10.1007/s10567-013-0146-y

References

9. David Wood, Moral Injury http://projects.huffingtonpost.com/moral-injury

10. Chris Amidon, Moral Injury, PTSD and VA Disability, https://www.hillandponton.com/moral-injury-ptsd-and-va-disability/

11. Moral Injury, GoodTherapy.org, http://www.goodtherapy.org/blog/psychpedia/moral-injury

Moral Injury

A SpiritualPerspective

“The Soul”

Much like the subconscious in psychology, you can’t see it, prove it, disprove it—it “just is.”

The soul is not divorced from but manifested through the mind and body

Most traditions teach that our Soul is holy and pure—it is within this arena that chaplains work to facilitate reconciliation

of and reconnection with the soul amidst trauma, reclaiming inherent worth/value/purity

The Soul & Spirituality

“The deeper reality is not that you have a soul but that in your essential nature, you are a soul” (Alan Morinis)

Spirituality is a path toward discovering one’s soul

Spirituality cultivates a way of being vs. a way of doing

All of the world’s religions strive to move practitioners to a deeper place of existence – beyond the mind and to the

heart

Warrior Archetype

Based upon warrior narratives, which

focus on:

• courage,• self-sacrifice, • loyalty, • fidelity, • respect,• and love of comrades

Warrior Ethos(Warrior beliefs and creeds)

“Soldiers Creed” “Airmen’s Creed” “Sailor’s Creed”

“Creed of the U.S. Marine Corps.”

I am an American Airman.I am a Warrior;

I have answered my nation’s call.

I am an American Airman.My mission is to Fly, Fight, and Win.

I am faithful to a Proud Heritage,A Tradition of Honor,And a Legacy of Valor.

I am an American Airman.Guardian of Freedom and Justice,

My Nation’s Sword and Shield,Its Sentry and Avenger.

I defend my Country with my Life.

I am an American Airman.Wingman, Leader, Warrior.

I will never leave an Airman behind,I will never falter,And I will not fail.

The

Air

man

’s C

reed

Warrior Identity

Peacemaker

Enforcer/Avenger

Comrade

Protector

Photo Credit Michael Yon, 2005

U.S. Air Force photo by Senior Airman Chris Willis

Connection Between Spirituality and War

“War, which is inherently about destroying and killing, is the ultimate irreligious act. We break divine commandments and appropriate divine

responsibilities, taking life when we cannot give it back. When in hell and becoming its servant, we most need spiritual and religious teachings for

support and practice to guide our actions, to protect and heal our souls, and to bring peace to

victims and reconcile with the dead.”

(Ed Tick, Warrior’s Return)

Effects of War on the Soul“Legitimate Authority:”

Relationship with SelfRelationship with the Community (local and global)Relationship with the Divine

Credit:

AP photographer Eddie Adams

Spirituality and Trauma

Trauma and spirituality are inextricably connected

Spirituality is a healing path; it necessitates taking an inward journey to work through all places which distract [trauma]. . . in order to rediscover the Soul,

and to reconnect with meaning and purpose.

“Suffering ceases to be suffering . . . at the moment it finds a meaning.”

(Viktor Frankl)

Spiritual Interventions for MI

Historic Role of Chaplains• “Keepers of the Cloak”

• A Reminder of the Holy

Steps in Assessment:• Build rapport

• Identify spiritual/religious needs

• Facilitate ministry support

• Anxiety reduction, grief work, forgiveness, reconnection to community and self

St. Martin of Tours by El Greco

Spiritual Interventions for MI“Veterans with moral injury have souls in anguish, not a psychological disorder . . . many veterans do

not believe their struggles are psychological illnesses needing treatment. Instead, they experience their

feelings as a profound spiritual crisis that has changed them, perhaps beyond repair.”

Soul Repair: Recovering from Moral Injury after War, Brock and Lettini

Spiritual Interventions for MI

Spiritual Counseling

Calibrates

the moral compass of warriors who have been authorized to use lethal force in increasingly

complex situations.

Facilitates

soul repair – moves warrior from lamentation towards reconstruction of core values and self

worth.

Spiritual Interventions for MI

Religious and cultural therapies are not only possible, but may well be superior to what

mental health professions conventionally offer.

Jonathan Shay, Odysseus in America

The survival story is central to recovery from severe trauma. It’s not simply the telling of the story, it is the whole social process. If I have suffered some terrible

experience, I have to be socially empowered to tell the story. You have to

be empowered to hear and to believe and to remember it.

Jonathan Shay, Wartime, 2005

Spirituality and Trauma

“Spirituality is an arena that always involves healing, but only sometimes

includes curing” (Gerald May)

— a crucial differentiation when working within the arena of the Soul.

Contributions of the Chaplain

Ritual/Worship

Confession/absolution

Developing and/or reconnecting to sacred rhythms

Connecting to community

Religious texts

Responding to questions about religion

Stories of redemption and hope

Credit: postandcourier.com

CitationsMonk Kidd, Sue. When the Heart Waits. HarperCollins, NY 1990.

Morinis, Alan, Everyday Holiness: The Jewish Spiritual Path of Mussar. Boston and London: Trumpeter, 2008.

Tick, Ed.Warrior’s Return: Restoring the Soul After War. NY, Sounds True Publishing, 2014.

Brock, Nakashima Rita and Gabriella Lettini. Soul Repair: Recovering from Moral Injury after War. Boston, Beacon, 2012.

Frankl, Victor. Man’s Search for Meaning. Boston: Beacon Press, 1984.

Shay, Jonathan. Odysseus in America: Combat Trauma and the Trials of Homecoming. New York: Scribner, 2002.

Jonathan Shay, Voices in Wartime. Documentary. Written and directed by Rick King, 2005.

Klay, Phil. Redeployment. Penguin Press. March 4, 2014. New York City, NY.

May, Gerald G. Care of Mind, Care of Spirit: A Psychiatrist Explores Spiritual Direction. San Francisco, Harper and Row Publishing, 1982.

“Alethes”

Truth That Cannot Be Denied

“Sentiment Without Action is the Ruin of the Soul”

Edward Abbey

“I am not a human being having a spiritual experience; I am a spiritual being having a human experience.”

Tielhard de Chardin

SPIRITUAL BEINGS WITH A HUMAN BODY

Archetypes - characteristics that transcend time and space - Truths about our nature. We are spiritual beings with a human body conditioned by the culture

in which we exist

SOUL & SPIRIT

SOUL AND SPIRIT ARE INTERCHANGEABLE TERMS WITH NEGLIGIBLE DIFFERENCES

• Metaphorically:

• Spirit is represented by wind & fire

• Soul is represented by earth & water

GENESIS CREATION STORY

THE SOUL IS GOD’S BREATH

Ancient Greeks understood that a body without a soul was not living.

The soul/spirit animates the living organism

SOUL LOSS

Veterans speak of when they lost their soul

They felt as if their soul left their bodyCain and AbleSaul & David

Psalms & PTS Injury

“COMING HOME CAN BE THE HARDEST PART OF GOING TO WAR”

Sebastian Junger asserts in the June 2015 Vanity Fair that “PTSD is a crisis of connection and disruption, not an

illness that you carry with you”

THREE ESSENTIAL ELEMENTS FOR WELLNESS

CommunityRitual

HealingMalidome Patrice Some, a West African tribal elder, in his book “The Healing

Power of Africa”

WARRIORS’ JOURNEY HOME

Model for healing:Listen-Speak-Heal

Participants enter a healing circle with

the sacred intention of healing.

FORGIVENESS MEANS….

…..ABANDONMENT OF ALL HOPE OF A BETTER PAST.

Reconciliation

Restitution

SUPPORT TROOPS SUFFER FROM PTS(D)

• 10% of all military are involved in direct ground combat

• Brett Litz, Boston VA uses the phrase “moral injury”, often is foundational to PTSD

“CHRISTIAN CENTURY” NOVEMBER 13, 2013

When airman Brandon Bryan first began work as a drone operator, he thought he was part of a force for good. After six years of working from a base in Nevada, sitting at a console with vivid and violent scenes of Afghan and Pakistan villages 7,000 miles away, he changed his mind. His views about the morality of the operation changed when he saw a child vaporized on the screen and saw hundreds of people blown to bits. He walked away from $109,000 bonus with a severe case of PTSD and a final kill count of 1,626. “The number made me sick to my stomach”, he said.

“TRAUMA IS WHAT REMAINS AFTER THE EVENT.”

Dr. Shelly Rambo, author of “Spirit and Trauma”PTSI is not remembering but reliving events

Time between Death and ResurrectionHell is the god-forsaken place.

STORY TELLING…

…in community allows and encourages the past

to become a Teacher rather than allowing the past to be the Master….within the ritual of

community derives meaning from horrific

events

WAR IS…

A force beyond our imagination.

Unspeakably horrible. Not romantic or pleasant.

Destructive and affects all facets of our society

STEPS ON THE JOURNEY HOME:

Isolation & TendingAcceptance of the Warrior Destiny

Purification & CleansingStorytelling & Confession

Restitution in the Community (Han)Initiation

Resources:• Fields, Rick. The Code of the Warrior. New York. Harper Perennial. 1991.

•• Hillman, James. A Terrible Love of War. New York. The Penguin Press. 2004.

•• Jung, Carl G. Man and His Symbols. New York. Dell Publishing. 1968.

•• Junger, Sebastian. Tribe. New York. Hachette Book Group, Inc. 2016.

•• Rambo, Shelly. Spirit and Trauma. Louisville, Kentucky. John Knox Press. 2010.

•• Schluep, John. Soul's Cry. Tallmadge, Ohio. Good Place Publishing. 2014.

•• Schluep, John Heart and Soul Liturgy. Tallmadge, Ohio. Good Place Publishing. 2016.

•• Some', Malidome Patrice. Ritual: Power, Healing and Ceremony. New York. Penguin Books. 1993.

•• Tick, Edward. War and The Soul. Wheaton, Illinois. Quest Books. 2005.

•• Trungpa, Chogyam. The Sacred Path of The Warrior. Boston/London. Shambala Publications, Inc. 1988.

•

Questions ???