PTSD and Moral Injury in Service Members and Veterans

PTSD AND MORAL INJURY IN SERVICE MEMBERS

AND VETERANS

Chaplain Kerry HaynesD.Min., M.Div., BCC/MHMental Health Chaplain

San Antonio VA

OBJECTIVES• Describe moral injury• Differentiate moral injury from PTSD• Review mental health (MH)

interventions for moral injury• Address possible MH and chaplain

approaches to moral injury

MORAL INJURY DEFINITION #1 (SHAY, 1994)

1. A betrayal of what’s “right” 2. By someone who holds

legitimate authority3. In a high stakes situation

But what if the “someone” is YOU?

MORAL INJURY DEFINITION #2 (LITZ ET AL., 2009)

Harm caused by “perpetrating, failing to prevent, witnessing, or learning about actions that violate deeply held moral beliefs and expectations “

Litz et al., 2009. “Moral injury and moral repair in war veterans: A preliminary model and intervention strategy.” Clinical Psychology Review, 29, 695-706.

MORE FROM LITZ ET AL.“Thus, the key precondition for moral injury is an act of transgression, which shatters moral and ethical expectations that are rooted in religious or spiritual beliefs, or culture-based, organizational, and group-based rules about fairness, the value of life, and so forth.”

Litz et al, 2009. “Moral injury and moral repair in war veterans: A preliminary model and intervention strategy.” Clinical Psychology Review, 29, 695-706.

IN THE EYE OF THE BEHOLDER

• Moral transgression is subjective• Based on Veteran’s own moral

standards, expectations, and interpretation

MODEL OF MORAL INJURY

Transgressive Act

Moral Dilemma

Moral Injury

Sheila Frankfurt, Ph.D., VISN 17 Center of Excellence for Research on Returning War Veterans, “Impact of Moral Injury on Post-deployment Mental Health

SOME CAUSES 0F MORAL INJURY• Acts of betrayal by peers, leaders, or self• Disproportionate violence inflicted on others• Death or harm to civilians• Violence within military ranks• Concealed acts of cowardice, failure to do

duty• Exposure to body parts• Inability to prevent death or suffering

Resulting in ethical dilemmas or moral conflicts

PTSD

• Anxiety & fear• Diagnosis in

DSM-5• Does not

require moral injury

• Guilt & shame• Dimensional

problem• Does not

require PTSD

MORAL INJURY

AvoidanceRe-

experiencingGrief/Loss

Hypervigilance

Guilt/Shame

Focus on fear-based responses

Treatment based on exposure and re-evaluation of cognitions

Higher sense of alienation and purposelessness

Treatment addresses moral conflict and self-condemnation

PTSD Moral InjurySYMPTOMS OVERLAP

Jaimie Lusk and Rebecca Morris, “Religion/Spirituality and Suicidality.” Presentation given at Portland, OR VA, June 30, 2016.

FEAR CONDITIONING, LOSS, AND MORAL INJURYA

William P. Nash, “Common Goals for Preventing and Repairing Moral Injury,” DCoE Chaplains Working Group Teleconference, 4 March 2015.

THE CASE OF THE USS MORTON (DD-948)

David A. Thompson, “Moral Injury: An Often Untreated Veteran Injury,” in The Military Chaplain, Fall 2014; pp. 6-8.

THE CASE OF THE USS DUBUQUE (LPD-8)

David A. Thompson, “Moral Injury: An Often Untreated Veteran Injury,” in The Military Chaplain, Fall 2014; pp. 6-8.

TWO ROUTES TO TRAUMA

1. Terror of one’s own vulnerability (PTSD?)The world is not benevolent nor meaningful. I am not protected by virtue of who I am or what I do.

2. Horror of one’s own immorality (PTSD and/or moral injury?)I am not worthy. I am not acceptable to the human community.

Ronnie Janoff-Bulman, “Shattered Assumptions: Toward an Understanding of Trauma,” Presentation to VA Chaplains, April 9, 2013

MODERN WARFARE• Better medical care prolonging life• More lethal weapon systems• Ambiguous enemy (indigenous

insurgents)• Atrocities involving civilians

DISTINCTION BETWEEN MORALITIES • Interpersonal• Morality in the context of one-to-one

interactions• Basic rule: “do no harm”

• Group• Morality in the context of group

memberships• Basic rule: “protect the group”

Ronnie Janoff-Bulman, “Shattered Assumptions: Toward an Understanding of Trauma,” Presentation to VA Chaplains, April 9, 2013

WHEN VETERANS COME HOME• Shift to completely changed context

(default to interpersonal morality) • Removed from war context• Not with buddies/unit • With others who use interpersonal

standard and don’t understand war experiences• Veteran no longer understands: horror

of his/her own immorality Ronnie Janoff-Bulman, “Shattered Assumptions: Toward an Understanding of Trauma,” Presentation to VA Chaplains, April 9, 2013

COPING: REBUILDING ONE’S WORLD

• Fundamental assumptions that can incorporate experiences, yet allow for adaptive functioning• Re-establishing relative sense of invulnerability• Re-establishing sense of self worth, morality

Ronnie Janoff-Bulman, “Shattered Assumptions: Toward an Understanding of Trauma,” Presentation to VA Chaplains, April 9, 2013

SOCIAL SUPPORT • Crucial for coping• Protective factor • Provides evidence that:• World is benevolent, meaningful• Survivor is deemed worthy

• Counseling – provides understanding confidant

• Groups = mini-community

Ronnie Janoff-Bulman, “Shattered Assumptions: Toward an Understanding of Trauma,” Presentation to VA Chaplains, April 9, 2013

IMPLICATIONS FOR CARESensitivity to the two types of trauma

• Terror of one’s own vulnerability:• We can minimize likelihood of negative

events• Horror of one’s own immorality :• Keep in context: What seems terrible now

was done in another setting (war) that involved different moral standards (protecting the group as paramount)

• Consider self-forgiveness/making amendsRonnie Janoff-Bulman, “Shattered Assumptions: Toward an Understanding of Trauma,” Presentation to VA Chaplains, April 9, 2013

MULTI-DIMENSIONAL MORAL REPAIR

William P. Nash, “Common Goals for Preventing and Repairing Moral Injury,” DCoE Chaplains Working Group Teleconference, 4 March 2015.

POST-TRAUMATIC GROWTH (PTG)

• The world isn’t always meaningful, but one can create meaning (value) through commitments and newfound appreciation of life• Recognize possibility for good and bad in

all of us – can choose the good • Greater compassion for others – Veterans

helping Veterans• Agonizing experiences bring the possibility

for profound growth

EVIDENCE-BASED TREATMENTS

Prolonged Exposure Therapy (PE)Repeated exposure of trauma-related thoughts, feelings and situations• Education• Breathing (self-soothing)• Real-world exposure practice• Talking through the trauma• Not so effective with shame (reliving)

EVIDENCE-BASED TREATMENTSCognitive-Processing Therapy (CPT)• Tackles assimilated/distorted beliefs related to the

trauma and over-generalized beliefs about oneself and the world

• Clients identify “stuck points” (conflicting beliefs, leaps of logic, or unsupported assumptions)

• May include work on guilt (appropriate vs. inappropriate) and acts of perpetration

• Providers may not include helpful spiritual/religious practices important to patient

MORAL INJURY AS CATALYST FOR MANUFACTURED EMOTIONS

• Associated with guilt, shame, and anger at self and others

• Guilt – what I did• Shame – who I am

• Work to reduce/eliminate inappropriate manufactured emotions • Work to right-size appropriately-placed

guilt

TREATMENTS UNDER TRIALImpact of Killing in War (IOK)• Six-session cognitive-behavioral group• Education on bio-psycho-social aspects

of killing in war that may cause inner conflict

• Identification of meaning elements and cognitive attributions

• Self-forgiveness (cognitive therapy and/or spiritual/religious practices)

• Making amends tailored to the individual

TREATMENTS UNDER TRIAL

Adaptive Disclosure (AD)• Eight-session group• Addresses moral injury and traumatic loss• Brief exposure to address core features and

meaning of combat trauma events• If focal trauma is loss-based, imaginary real-

time dialogue with the lost person• For moral injury, guided real-time dialogue with

a forgiving and compassionate moral authority

WHY INVOLVE THE CHAPLAIN?• Specialist in guilt, shame, forgiveness, restoration, community, and ritual•Moral/ethical authority• Representative of the Divine• Less stigma than seeing a MH provider?

INDISPENSABLE QUALITIES FOR PROVIDERS IN MORAL INJURY

WORK

• Non-judgmental• Non-anxious• Compassionate• Patient with the

struggle• Transparent

(appropriately)• Engaging where they

are

GROUP VS. INDIVIDUALINDIVIDUAL

• Less threatening initially (with warm, accepting chaplain)• Tailored to unique

needs• More time intensive• Less community

building

GROUP• More threatening

initially (unless safety in numbers)• Less tailored to

unique needs• Less time intensive• More community

building

GROUP OPTIONSOPEN

• Easier to try out• Easier for referrals• Source for closed

group recruitment

CLOSED

• Higher commitment level• Builds trust quicker• Builds stronger

community• More appropriate for

moral injury?

OPTIONS FOR FACILITATION

•Mental health (MH) provider alone• Chaplain alone• Chaplain and MH provider co-leading

VA MORAL INJURY GROUPS CO-LED BY MH PROVIDER AND CHAPLAIN

•Memphis •Nashville• Portland• Loma Linda

• Providence•Mountain Home• Philadelphia• Indianapolis

VA MORAL INJURY GROUPS LED BY CHAPLAIN ALONE

•Hampton• San Diego• Charleston• San Antonio

SAN ANTONIO VA INITIATIVES

• Open ongoing PTSD Ch.-led group• Closed Ch.-led moral injury groups (6-12

sessions)• Testing Spiritually-oriented Cognitive

Processing Therapy (SOCPT) • Research study with Harold Koenig, M.D.

SPIRITUALLY-ORIENTED COGNITIVE PROCESSING THERAPY (SOCPT)

• Targets erroneous interpretations of trauma• Focuses on cognitive restructuring using

clients’ religious resources to challenge maladaptive thinking patterns • Targets moral injury• Targets religious/spiritual struggles and

loss of faith Pearce MP, Haynes K, Koenig HG (2016). “Spiritually Oriented Cognitive Processing Therapy.” Durham, NC: Duke University Center for Spirituality, Theology and Health. Appendix [planned] to Resick et al. (2014). “Cognitive processing therapy: Veteran/military version: Therapist’s manual.” Washington, DC: Veterans Administration.

SPIRITUALLY-ORIENTED COGNITIVE PROCESSING THERAPY

• Seeks to reverse negative emotional responses (shame, guilt, anger, humiliation) by emphasizing healthier concepts of …• Mercy• Grace• Confession• Repentance• Penance• Forgiveness

• Spiritual surrender• Prayer/

contemplation• Divine justice• Hope• Divine affirmations

SPIRITUALLY-ORIENTED COGNITIVE PROCESSING THERAPY

• Includes powerful rituals• Encourages engagement in Veteran’s

chosen religious community• Addresses moral injury from within the

person’s own spiritual/religious system• Future writings: • Chaplain intervention for moral injury• Religious-specific SOCPT manuals

RESEARCH STUDY• Multi-site study for combat Veterans with

PTSD symptoms• Coordinated by Harold Koenig, M.D., Duke

U.• Measures Veterans’ …• PTSD symptoms• Moral injury symptoms• Openness to spiritually-oriented therapy

• Future study: effectiveness of SOCPT vs. CPT

MORAL INJURY PROGRAMS AND A FILM PREMIERE

• Sunday, November 20, 2016, 1-7 pm• Grand Hyatt Hotel, Texas Rooms E & A• Free and Open to the Public• Dress: Business Casual• Hosted by the Soul Repair Center at Brite

Divinity School, the Moral Injury in Religion, Society, and Culture Group of the American Academy of Religion, and Odyssey Networks

BRANDON COURTNEY• Poetry Reading, November 1, 6:00

pm• Seddon Recital Hall, University of

Incarnate Word• Q&A and Book Signing• Award-winning poet and veteran

of the Navy and Operation Enduring Freedom• For additional information,

contact:• Dr. Joshua Robbins

(joshua.robbins@uiwtx.edu)• Dr. Zenon Culverhouse (fculverh@uiwtx.edu)

QUESTIONS/COMMENTS?

Kerry Haynes, D.Min., BCC/MHMental Health Chaplain

San Antonio VA210-617-5300, ext. 13317

Kerry.Haynes@va.gov

BIBLIOGRAPHYBrock, Rita and Gabriella Lettini. Soul Repair: Recovering from Moral Injury After War. Boston: Beacon Press, 2012.Currier, Joseph, Jason Holland, and Jesse Malott. “Moral Injury, Meaning Making, and Mental Health in Returning Veterans.” Journal of Clinical Psychology 71, no. 3 (March 2015): 229–240.Currier, Joseph, Jason Holland, Kent Drescher, and David Foy. “Initial Psychometric Evaluation of the Moral Injury Questionnaire-Military Version.” Clinical Psychology and Psychotherapy 22, no. 1 (2015): 54-63.Drescher, Kent, David Foy, Caroline Kelly, Anna Leshner, Kerrie Schutz, and Brett Litz. “An Exploration of the Viability and Usefulness of the Construct of Moral Injury in War Veterans.” Traumatology 17, no. 1 (March 2011): 8-13.  

BIBLIOGRAPHYGray, Matt J, Yonit Schorr, William Nash, Leslie Lebowitz, Amy Amidon, Amy Lansing, Melissa Maglione, Ariel Lang, and Brett Litz, “Adaptive Disclosure: An Open Trial of a Novel Exposure-based Intervention for Service Members with Combat-related Psychological Stress Injuries,” Behavior Therapy 43, no. 2 (June 2012), 407-415.Handzo, George. “Spiritual Care and Moral Injury in Service Members.” Caring Connections 10, no. 1 (Winter 2013): 6-8. Kidwell, Julia and Nathaniel Wade, “Christian-Accommodative Group Interventions to Promote Forgiveness for Transgressions,” in Evidence-based Practices for Christian Counseling and Psychotherapy. Edited by Everett Worthington Jr., Eric Johnson, Joshua Hook, and Jamie Aten (Downers Grove: InterVarsity Press, 2013): 149-160.

BIBLIOGRAPHYKim, Jichan and Robert Enright. “A Theological and Psychological Defense of Self-Forgiveness: Implications for Counseling.” Journal of Psychology and Theology 42, 3 (2014): 260-268.Kinghorn, Warren. “Combat Trauma and Moral Fragmentation: A Theological Account of Moral Injury.” Journal of the Society of Christian Ethics 32, 2 (2012): 57-74. Koenig, HG, NA Boucher, JP Oliver, N Youssef, SR Mooney, JM Currier, and M Pearce. “Rationale for Spiritually Oriented Cognitive Processing Therapy for Moral Injury in Active Duty Military and Veterans with Posttraumatic Stress Disorder.” Journal of Nervous and Mental Disease 2016 (to be published).

BIBLIOGRAPHYLitz, Brett. Nathan Stein, Eileen Delaney, Leslie Lebowitz, William Nash, Caroline Silva, Shira Maguen. “Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy.” Clinical Psychology Review 29, no. 8 (December 2009): 695-706.Maguen, Shira and Brett Litz. “Moral Injury in the Context of War.” Last modified January 20, 2015, accessed February 18, 2015. http://www.ptsd.va.gov/ professional/co-occurring/ moral_injury_at_war.asp.McConnell, John and David Dixon. “Perceived Forgiveness from God and Self-forgiveness.” Journal Of Psychology and Christianity 31, no. 1 (2012): 31-39.

BIBLIOGRAPHYMeagher, Robert. Killing from the Inside Out: Moral Injury and Just War. Eugene: Cascade, 2014.Orban, Michael. Souled Out: A Memoir of War and Inner Peace. Candler, North Carolina: Silver Rings Press, 2007.Pearce MP, Haynes K, Koenig HG (2016). Spiritually Oriented Cognitive Processing Therapy. Durham, NC: Duke University Center for Spirituality, Theology and Health. Appendix [planned] to Resick et al. (2014). Cognitive processing therapy: Veteran/military version: Therapist’s manual. Washington, DC: Veterans Administration.

BIBLIOGRAPHYRiek, Blake M. “Transgressions, guilt, and forgiveness: a model of seeking forgiveness.” Journal Of Psychology and Theology 38, no. 4 (January 2010): 246-254.Shay, Jonathan. Achilles in Vietnam: Combat Trauma and the Undoing of Character New York: Simon and Schuster, 1994._____. “Moral Injury.” Psychoanalytic Psychology 31, No. 2 (2014): 182–191. _____. Odysseus in America: Combat Trauma and the Trials of Homecoming. New York: Scribner, 2002.Shay, Jonathan and J. Munroe. “Group and Milieu Therapy for Veterans with Complex Posttraumatic Stress Disorder.” In Posttraumatic Stress Disorder: A Comprehensive Text, edited by Philip Saigh and J. Douglas Bremner, 391-413 (Boston: Allyn and Bacon, 1998).

BIBLIOGRAPHYSherman, Nancy. Afterwar: Healing the Moral Wounds of our Soldiers. New York: Oxford University Press, 2015.Tick, Ed. War and the Soul: Healing Our Nation’s Veterans from Post-traumatic Stress Disorder. Wheaton: Quest Books, 2005._____. Warrior’s Return: Restoring the Soul After War. Boulder: Sounds True, 2014. Worthington, Everett. “Self-condemnation and self-forgiveness.” Bibliotheca Sacra 170, no. 680 (October 1, 2013): 387-399.Worthington, Everett and Diane Langberg. “Religious Considerations and Self-Forgiveness in Treating Complex Trauma and Moral Injury in Present and Former Soldiers.” Journal of Psychology and Theology 40, no. 4 (2012): 274-288.