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Krista
Krebs
, PhD
Sept 15
2017
Acknowledgments & Disclosures ● With gratitude to Margo Norton, PhD, VA psychologist at the Fargo, VA, with whom I worked on an early version of this presentation for our VISN 23 PTSD Mentoring group in September, 2013 ● With gratitude to Dr. Jerry Bockoven who has conducted several talks to diverse audiences on this subject, and has been open and willing to share his thoughts and slides. ● I do not have any financial stake in any of the models, treatments, resources, etc. mentioned in the presentation. I do not speak for VA.
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Objec7ves 1. Familiarize attendees with the
definition of and ideas about moral injury
2. Develop understanding of how moral injury is related to PTSD
3. Describe ways in which wartime experiences may be uniquely injurious
4. Describe the emerging literature and practice data base about interventions for moral injury
NOTE…
● Mostly combat related examples used today ● Military Sexual Trauma has powerful moral injury elements ● Many Veterans say that their distress/impact from MST is worse than their combat-‐related distress
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Origins… Marin, 1981 Living In Moral Pain “…profound moral distress, arising from the realization that one has committed acts with real and terrible consequences.”
Shay, 1994 Achilles in Vietnam “…moral injury is an essential part of any combat trauma that leads to lifelong psychological injury. Veterans can usually recover from horror, fear, and grief once they return to civilian life, so long as “what’s right” has not been violated.”
Moral Injury Defined ● [the] impact of perpetrating, failing to prevent or bearing witness to acts that transgress deeply held moral beliefs and expectations. (Litz, 2015) ● The psychological consequence of a betrayal of what’s right by someone who holds legitimate authority in a high-‐stakes situation (Shay, 2002) ● Many leaders in MI treatment distinguish between perpetration based and betrayal based MI
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Defini7ons con7nued ● Witnessing perceived immoral acts, especially if it causes suffering or death to others ● Failure to stop those acts by others ● Or doing them yourself, Creates: ● Perceived transgression—often regardless of perceived necessity of the act ● Loss of expectation of just and ethical behavior (others and myself) ● Expectation of or belief in the need for punishment
Combat Zone Stressors Unique? ● Insurgency: “non-‐combat” MOS loses meaning? ● Combat deployments: 19 deployments WW2 to VN (27 years), 144 since 1973
● Long wars + all volunteer military: disconnect btw consequence of war and the gen. pop.
● Distorted Views: wounded/damaged or heroes
though less than 8% of the pop., 20% of America’s suicides are military Veterans, (Hoge et al)
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Brock & LeJni’s list (2012) ● Witnessing ill and/or wounded and not being able to help ● Exposure to human remains, especially those of civilians, or fellow service members ● Handling human remains ● Being responsible for the death of a civilian, especially a child ● Witnessing sectarian violence ● Damaging or desecrating human remains ● Killing ● Severe or brutal interrogation techniques ● Failing to or choosing not to prevent the above acts by others ● Bearing witness to the aftermath of such events
The Innocent Suffer
THEN
AND NOW
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Killing ● LTC Kilner: “Killing is central to our profession, and it is a huge moral issue. We already train our soldiers to kill effectively; let’s train them to live effectively after they kill.” ● “When unjust combatants refuse to wear uniforms, just soldiers bear the burden of identifying those who have [hostile intent]” ● Good rules of engagement provide guidelines to assist that decision-‐making process” ● “The message is: go off to war, suspend these values and taboos that you've been taught, and then pick them back up when you return” Litz, 2015, personal communication
Litz, Nash, et al asser7ons ● We use treatment models developed for civilians, but trauma in the military world seems to be different (unique/complex?) ● 4 Harm Domains Threat to life/danger-‐based harm Traumatic loss Moral injury Removal from your ”regular” life ● Most tx models, are about that first type of harm
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PTSD does not adequately explain ● Events that affect people “beyond the realm of fear and imminent threat to one’s physical safety” (Farnsworth, et al, 2014, page 250).
● MI is more associated with re-‐experiencing, avoidance (and negative emotional states), and less so with hyper-‐vigilance
● More guilt, disgust, betrayal, and shame based ● It may be part of PTSD for many service members, AND it may be the main issue when we find someone who does not meet all criteria for PTSD but who has debilitating re-‐experiencing/avoidance symptoms
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Emerging Evalua7on Methods
Moral Injury Events Scale ● I saw things that were morally wrong ● I am troubled by having witnessed others’ immoral acts ● I acted in ways that violated my own moral code or values ● I am troubled by having acted in ways that violated my own morals or values
● I violated my own morals by failing to do something that I felt I should have done
● I am troubled because I violated my morals by failing to do something that I felt I should have done
● I feel betrayed by leaders who I once trusted ● I feel betrayed by fellow service members who I once trusted
● I feel betrayed by others outside the US military who I once trusted
*Nash et al, 2013
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Killing Cogni7ons Scale ● Shira Maguen and colleagues at the University of California, San Francisco/VA San Francisco have developed a scale specific to killing
Examples of embedded questions. ● During combat operations did you become wounded or injured?
● During combat operations did you personally witness anyone being killed?
● During combat operations was someone close to you killed?
● During combat operations did you see the bodies of dead Soldiers or civilians?
● During combat operations did you kill others in combat (or have reason to believe that others were killed as a result of your actions)?
Killing Cogni7ons Scale ● Sample items from Dr. Maguen’s presentation February 18, 2015: ● I deserve to suffer for killing. ● I feel betrayed by my superiors who ordered me to kill against my own beliefs. ● I can no longer be intimate with a partner after killing.
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It’s not only fear: Main Emo7onal Components
Fu7lity: I would do it again the same “Moral injury results when soldiers violate their core moral beliefs, and in evaluating their behavior negatively, they feel they no longer live in a reliable, meaningful world, and can no longer be regarded as decent human beings. They may feel this even if what they did was warranted and unavoidable”. (Maguen & Litz, 2012)
● Excerpt from “Shooting at Ghosts”, Marine recounts events in Iraq
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Trauma7c Loss ● loss of a comrade is often experienced as an exquisitely painful experience
● complicating factors such as feelings of shame/guilt that “I didn’t keep them safe” or “they took my bullet” or “why them and not me”
● Survivor guilt: I did something wrong by living
Not just brotherhood—reciprocal parent/child relationship
Loss Can Lead to Vengeance ● Desire for revenge following the death of a comrade can increase the chance of engaging in behavior that may later lead to moral injury.
Such losses can lead to “the shrinkage of the social and moral horizon”(Shay, 1994)
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Betrayal Leads to Disgust, Contempt, Rage, Aliena7on ● “treated like mushrooms: kept in the dark and only fed shit”
● “Let the burned bridges light your way” ● “Weaponize my experience” ● “Chained in a well of Hate” ● “I have to keep my darkness”
“I feel like a stone in a field of cotton” trapped among SHEEPLE
Guilt and Shame ● Guilt increases motivation to correct behavior ● Shame could lead you to be the best version of yourself; can lead you to live as true to your own values as possible.
● “service members will be convinced and confident that not only their actions, but they are unforgivable.” (Brock & Lettini, 2012)
● “I have innocent blood on my hands” ● Conceal ● Contain ● Hide
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Emo7onal Numbing ● “I accepted I would die, and I felt better, because nothing mattered any more”
● Dampened emotions as a response to fear of loss/betrayal/abandonment/danger or loss of vigilance
● Loss of "positive" or wanted emotions, and the ability to savor our experiences
● Thawing out hurts: “It’s like being in the dark and the sun suddenly comes out”: scary and shocking
Loss of meaning ● “When the narcotic emotional intensity and tight comraderie of war are gone, withdrawal can be intense.
● As memory and reflection deepen, negative self judgments can torment a soul for a lifetime.
● It sinks warriors into states of silent, solitary suffering, where bonds of intimacy and care seem impossible. Its torments to the soul can make death a mercy.” (Maguen &Litz, 2012)
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Brief scene from Korengal ● Sebastian Junger, war correspondent, and Tim Hetherington, photojournalist made multiple trips to the Korengal Valley in eastern Afghanistan in 2007 and 2008.
● They filmed with Army personnel stationed on remote outposts who were tasked to win over locals and disrupt supply lines into Afghanistan through the mountainous terrain from Pakistan.
● There are two documentaries, Restrepo and Korengal, and a book “War” by Sebastian Junger (2010) based on their experiences there.
● https://www.youtube.com/watch?v=qvy99cqQjqA
Promp7ng Disclosure and Challenging Beliefs
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Jordan et al (2017) “For the morally injured, treatment strategies that facilitate forgiveness of self or others, making amends, or engagement in the re-‐experiencing of the inherent goodness in humanity may be more helpful than repeated emotional processing of one’s own or others’ perceived moral failings, or minimizing perceived culpabilities as distortions caused by hindsight bias.”
Requires a Different Tx focus ● Guilt, shame, sorrow/anguish do not extinguish like fear does ● Common beliefs show up—especially that one will eventually be judged/punished ● Shift from a re-‐conditioning of the NS to a reattachment/reconnection focus ● Shift to “corrective action” on the part of the service member and their social network
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Facilita7ng Disclosure ● fostering an atmosphere of not only validation but explicit “condemnation free zone” ● It is critical that Veterans be willing and able to disclose these facets of their combat experience ● Need to recognize that killing within the rules of engagement and killing outside the rules of engagement may feel different to the Veteran ● There is often fear of retribution or legal ramifications for both, especially for the latter ● There is fear of being condemned/judged by the therapist or family members
Therapist-‐Driven Barriers ● Not sure how to bring it up, or fear that it will worsen sx ● Concern that the therapist will now see the Veteran differently and that this will interfere with the therapeutic relationship ● Discomfort with asking questions related to these concepts ● Discomfort with situations for which the Veteran’s guilt and shame may be appropriate ● Concern about seeming to approve of or have sympathy for unacceptable acts
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Broaching the subject ● Don’t assume someone’s killing event(s) =guilt or PTSD. ● At the same time, ensure don’t use language and other forms of communication to make it less likely that the Veteran will talk about it if it’s “the” trauma. ● Educate that combat exposure brings trauma from at least 3 directions: what happened to you, what you saw happen to others, and what you did or did not do (following ROEs or not) ● Give Moral Injury handouts, Use the MIES ● Have them read the Huffington Post blog on moral injury
Play the Long Game ● Veteran you complete EMDR/PE/CPT with today may well be the person who returns in several more years saying “this is the The Real One.” ● We cannot be smug or certain in our own morality when it has not been tested in the crucible of unwinnable situations. ● Neither condemnation nor excuse-‐making or minimization are useful ● Forgiving, compassionate and judgement-‐free—coupled with clear expectation of the ability to act in an ethical and moral way.
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Culpability Re-‐conceptualized Veterans may completely believe: that they should have been able to prevent all harm that they should have been able to control it ● forget that they are often in a situation where they must very quickly, under severe duress, choose from amongst their meager alternatives for the least awful one
● culpability is an inappropriate/inaccurate judgment because of role and context
● I killed that child is not the same as I murdered that child-‐-‐-‐moral reassurance
Culpability: Reality-‐based? ● Veteran may have a real basis for feeling culpable ● assume both that there is some kind of transgression and that there isn't: disclosure unfolds
● Explicit agreement that accuracy of culpability will be discovered and faced together, w/o repercussions, shaming, judgement from you
● If shame/guilt is appropriate—moral repair ● “shift beliefs from blameworthiness (which may be objectively true) to forgiveness and compassion (which are nonetheless possible), and in so doing to facilitate the potential for living a moral and virtuous life going forward” (Litz et al, 2015)
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Moral Injury "stuck point" beliefs ● I am evil and unforgivable ● I have been stained, ruined, because of what I did and I am irredeemable. (contaminated) ● I am not safe to be around innocents ● Anyone close to me will get hurt ● I am a monster ● If my loved ones find out, they won’t love me anymore ● I cannot trust myself ● Even if God has forgiven me, it is wrong to forgive myself. ● The universe will punish me
I’m meant to suffer ● If I don't suffer for what I've done: -‐-‐that's wrong, someone has to pay -‐-‐I will feel even worse/more guilty -‐-‐I could do it again -‐-‐people I love will suffer instead -‐-‐it would mean I don’t care about what happened
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Challenging“I must suffer, die” ● What is the purpose of your suffering/punishment: are you going to do it again? Will the suffering undo what happened? ● Will you one day reach the right level of punishment and it will be over? ● Your suffering compounds the problem and adds suffering to your loved ones, who do not get to have you ● Your life is not yours to take-‐-‐if we die, we don't lose our life, other people lose our life
Recent Treatment Models
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Military Culture • We must educate ourselves about military
culture • Very helpful to educate yourself about
specific wars • MI reading list, bold = especially helpful to
understand military culture • Military blogs:
https://www.thewarhorse.org/ • Military Culture: Core Competencies for
Healthcare Professionals: http://www.deploymentpsych.org/military-‐culture
Treatment sugges7ons cont’d ● Help Veterans understand ego-‐dystonic violent thoughts as stemming from their histories not necessarily from their character. ● Smith, Duax, & Rauch (2013) argue that PE contains therapeutic elements to sufficiently address perceived perpetration/moral injury, others suggest that new models of treatment specific to moral injury are needed. ● Potential paths for reparation *Drescher, 2011 ● Spiritually directed ● Socially directed ● Individually directed
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Impact of Killing Treatment ● Maguen et al working on a randomized controlled clinical trial of an “Impact of Killing” module designed to be utilized for Veterans who have already received significant CBT treatment for PTSD (ideally trauma focused) ● Designed for Veterans impacted by killing in combat, or by feelings of responsibility for the death of others in combat. ● It is a 6-‐8 session module of treatment utilizing sessions on: common responses to killing, CBT elements, becoming unstuck, forgiveness, and taking the next step (forgiveness letters, making amends, and maintaining gains).
IOK INVOLVES… ● Education about the complex interplay of the biopsychosocial aspects of killing in war that may cause inner conflict and moral injury.
● Identification of meaning elements and cognitive attributions related to killing in war.
● Self-‐forgiveness (which entails cognitive therapy and for some the promotion of spirituality or faith-‐based religious practices).
● Making amends tailored to the individual (this may include writing forgiveness letters and an action plan to start the process of making amends).
**personal communication, Maguen, S. (January, 2016)
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Trauma-‐Related Guilt, Norman et al (2014) 4 modules: “justification analysis”, “responsibility analysis”, and “wrong doing analysis”, and preventability analysis a. Have them describe the event and their perception of their degree of responsibility for it b. Challenge their minimization of the role of others who were present c. Challenge their minimization of the role of others who were not present d. Challenge their perception of their degree of responsibility for the event
Adap7ve Disclosure ● 6-‐8 (90 min) session series, initially tested on 44 active duty Marine and Navy Personnel stationed at Camp Pendleton, with positive response ● Current study underway by Litz and Steencamp, at Boston VA, comparing it to CPT-‐C. ● Detailed treatment description/manual recently available in book form
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Goals of Adap7ve Disclosure ● Make beliefs explicit so they can be examined ● Modify negative expectations about disclosure ● Reclaim goodness and self-‐worth ● Acceptance of legacy of experiences and hope ● Promote self-‐efficacy about inevitable periods of painful recall
● Develop a healthy payback plan—making amends? ● Be explicit over and over about your seeing the goodness in them and about their suffering not being useful.
Important Elements of Interven7on ● Therapeutic engagement/trust establishment ● Preparation and education ● Detailed disclosure of morally injurious events ● (Imaginal) dialogue with a compassionate moral authority
● Apportioning blame ● Reparation (make or seek amends) and forgiveness ● Acceptance-‐fostering ● Fostering reconnection *Litz et al., 2009, 2013, 2015
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Adap7ve Disclosure ● Recommendations from Litz, personal communication, December 2015 ● Be compassionate and unconditionally forgiving in your therapeutic stance. Remember shame and help seeking is proof he/she is not psychopathic.
● Avoid minimizing, or “putting a smiley face” on what he/she is describing. Appreciate it from his/her vantage point.
● Be evocative, provocative, poignant, and always deeply caring
● Remember shame does not extinguish like fear ● Identify ways to foster corrective experiences
Adap7ve Disclosure ● Recommendations from Litz ● If service member is religious, consider partnering with clergy/pastoral counsel
● Imaginal confession to a compassionate moral authority
● Goal is NOT to reclaim an entirely good self. The act will forever define him/her to some extent. The important realization is that all people have good and bad parts.
● If the moral injury is severe, and he/she is haunted, consumed, and self condemning, the recovery process will be take much longer than one episode of therapy
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EMDR/CPT/PE + Adap7ve Disclosure reclaim goodness and humanity, and manifest those parts of themselves tangibly in their actual lives EXAMPLES ● M: In vivo’s of reconnection: play FB with the child
● R: In Vivo’s of reconnection: hold your grandson ● J: Review of CPT + Adaptive Disclosure
RESOURCES
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Mo7va7onal Enhancement ● It’s not readiness, it’s hope ● Talk about the brain!! ● Share decision making ● Teach about emotion ● Many service members are totally inexperienced when it comes to disclosing and sharing about inner experiences ● Teach about moral injury ● Address psychopathy fears
Enhance Hope for Change ● Goals for change—get very specific ● Find specific reasons beyond alleviating their own suffering
● Educate about how emotional reserve skills may not be the right skills for this job
● Must learn to notice your emotions/thoughts while not letting them RUN your life
● Develop a lot of analogies and metaphors: building a muscle, healing a wound to a nice scar, paradox of suppression (“don’t think about…”), letting the car run out of gas, self-‐blame = defense against helplnessness, haunting metaphor
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The ”worth it” factor… ● Pain is better than numbness: "painful" emotions are signals that we care, signals that people and things matter, signals that we have values and principles, signals that we do have thoughts of right and wrong.
● Spartan Pledge: “I will not take my own life by my own hand until I talk to my Battle Buddy first. My mission is to find a mission to help my warfighter family”
● Collaborate to treat comorbidities, and taper benzos? ● Use other Veteran testimonials: selected websites ● Ask them not to drink/use marijuana in homework ● Homework about their beliefs about QOL
Hopeful Goals ● make peace with your own mind ● feel a broad range of emotion to get the good stuff back ● be able to live according to your own values ● be the best version of yourself ● develop a life worth living ● reduce symptoms of PTSD ● let your loved ones have you back
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Transforma7on Goals Transform: ● Vengeance-‐seeking ● Extreme Injustice Rage ● Severe feelings of betrayal and abandonment ● Contempt for humanity (and self) ● Sentinelizing (Apart From) TO: ● Forgiveness (self and others) ● Compassion (self and others) ● Mission and amends making ● Reconnection ● Acceptance
A final idea… We are all so much more than the worst thing we’ve done
*Brock & Lettini, 2012
