Download PTSI And Moral Injury In Combat Veterans

Post Traumatic Stress Injury (PTSI)
and
Moral Injury in Combat Vets
Chaplain Robert Thomas, D Min BCC
Chief, Pastoral Care Service
VA Sierra Nevada Health Care System
Reno, NV 89502
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Definition of Terms
Post Traumatic Stress Disorder (PTSD)
- Classified under “Anxiety Disorders” in the Diagnostic Standards
Manual (DSM)-IV
- Moved under “Trauma and Stressor-Related Disorders” in DSM-5
“Direct exposure, witnessing, learning about, or experiencing repeated or
extreme adverse details about actual or threatened death, serious injury, or
sexual violence resulting in intrusion symptoms, avoidance characteristics,
negative alterations in cognitions, mood, arousal and reactivity which causes
clinically significant impairment in social, occupational or other important areas of
functioning.” (DSM-5 p. 271-2)
- Object to “disorder,” prefer “injury”– Post Traumatic Stress Injury
(PTSI)
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Injuries Relating to Combat
Post Traumatic Stress Injury (PTSI)
The person experienced, witnessed, or was confronted with event(s)
that involved actual or threatened death or serious injury, or a threat to
the physical integrity of self or others; response involved intense fear,
helplessness or horror.
Symptoms:
*anxiety
*hypervigilance
*increased arousal
*exaggerated startle response
*recurring dreams and nightmares
*irritability
*psychological distress
*anger
*avoidance behaviors
*difficulty concentrating
*psychic numbing
*foreshortened future
*isolation and estrangement
*sleep disorders
*anhedonia
Wound is psychological, but with very physical manifestations
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Moral Injury
Perpetrating, failing to prevent, or bearing witness to acts that
transgress deeply held moral beliefs and expectations; feelings
of betrayal.
*Feeling unforgiven and unforgivable
*Always on the margins of society (i.e., “don’t fit in” - withdrawal)
*Estranged from God, church or faith community, friends
*Feeling unheroic (“if you only knew what I did…”)
*Unreconciled spirit
*Feeling in perpetual state of moral ambiguity
*Seething anger and frustration
*Numbing behaviors (drugs, alcohol)
Wound is to the Soul and Spirit
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What is Missed by Current
Conceptions of PTSD?
Litz, et. al., 2009, Moral
Injury and Moral Repair
In War Veterans:
A Preliminary Model
PTSD
Moral Injury
(A1 Criterion)
Actual or threatened death,
serious injury or sexual violation
Acts that violate deeply
held moral values
Individual’s role at time of event
Victim or Witness
Perpetrator, victim or
witness
Witnessing, in person, the event(s) as it occurred to
others. (A2 Criterion)
Fear, horror, helplessness (DSMIV) DSM-5 includes guilt, horror,
shame
Guilt, shame, anger
Re-experiencing?
YES
YES
YES
YES
YES
NO
Safety
Trust
Directly experiences the traumatic event(s).
(B Criterion)
Persistent avoidance of stimuli?
(C Criterion)
Negative cognitions and mood, and arousal?
(D and E Criterion)
What necessity is lost?
DSM-5, p. 271-272
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The Honorable Work of the Warrior
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Psalm 18:34 “He trains my hands for battle; my
arms can bend a bow of bronze.” Rom 13:4
Bhagavad-gita 2.31, “And even considering
your personal dharma as well, it is not right for
you to hesitate. There is nothing better for a
warrior, than a fight based on dharma.”
R. Calloway, “A true warrior does not train
tirelessly to fight or to kill. A true warrior trains
endlessly that he/she may return home alive.”
Tom Clancy, The sum of all Fears, “The
noblest of ideas have always been protected by
warriors.”
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Even Honorable Warriors May
Experience PTSD
David: The valley of death-shadow (Psalm 23)
Sons of Korah: Rejection by the people following battle
in a foreign land (Psalm 44:13-16)
Warriors of Israel: Survived the battle (Psalm 107:2) but suffered
homelessness, poverty and rejection (vv. 4-5; 10-13)
People of Galilee: Living in death-shadow (oppression of foreign power), the
light of the Christmas Promise will shine and bring freedom (Isaiah 9:2-7)
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Philosophical/Theological Issue (Theodicy)
Theodicy: Arguments in defense of God’s goodness despite the
existence of evil.
Problem (Epicurus):
1. If God would remove all evil from the world but cannot = impotent.
2. If God can remove all evil from the world but will not = malevolent.
3. If God is able and willing to remove all evil, why is there evil?
“God went AWOL in Vietnam!”
“That’s when I decided God was not there.”
Wound is to the belief system (loss
or corruption of the assumptive world)
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Counterinsurgency and the Moral
Compass, Litz, 2009, Moral Injury
Despite strong battlefield ethics training and the rules of
engagement, unconventional features of war may make it more
difficult for service members to maintain a moral compass.

Over half of the soldiers felt that non-combatants should not be
treated with dignity and respect
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31% indicated they had insulted or cursed at civilians
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20% of soldiers reported responsibility for the death of a noncombatant
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17% of soldiers surveyed believed that non-combatants should be
treated as insurgents
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11% reported damaging property unnecessarily
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5% indicated mistreating civilians
Litz, Brett; et. Al.; Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention
Strategy, in Clinical Psychology Review, 2009.07.003
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Spiritual Consequence of War
Cipolla, Benedicta, Healing the Wounds of War, Religion & Ethics
NewsWeekly, 2007.11.30.
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Spiritual Consequence of War
Cipolla, Benedicta, Healing the Wounds of War, Religion & Ethics
NewsWeekly, 2007.11.30.
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Then There is the Chris Kyle
Experience
American Sniper
“I will stand before my Maker and give an account for every shot I took.”
- Kyle felt justified
- Morally and ethically approved
- Film is a study on the impact of PTSD and Moral Injury in spite of
moral justification
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Deployment Length and Multiple
Deployments
Can create cumulative anger and frustration about
losses, sacrifices, and adversities may impact
ethical decision-making.
For example: deployment length has been found to be
associated with an increase in unethical behaviors on the
Battlefield.
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Guilt
Guilt is a painful and motivating cognitive
emotional and spiritual experience tied to specific
acts of transgression of a personal or shared moral
code or expectation.
Guilt is not always a bad thing
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Shame
Shame involves global evaluations of the self along
with behavioral tendencies to avoid and withdraw.
It results in more toxic interpersonal difficulties,
such as anger and decreased empathy for others. These
experiences can lead to devastating life changes.
Research has shown that shame is more damaging to
emotional and mental health than guilt.
Consequently, shame may be a more integral part of moral
injury.
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Betrayal
Many soldiers experience moral injury as a
result of feeling betrayed by a trusted
authority or structure
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Tactical command structure (CO, LT, platoon sergeant)
Strategic command structure (Generals, Pentagon, Joint Chiefs)
Government (Congress, the President, SecDef)
Religious communities that marginalize the soldier/veteran
A nation that turned its back on all of them
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Guilt is what I feel for what I’ve done
External to self, because it focuses on self behavior
Shame is what I feel for who I am
Internal – is appraisal of the self
Betrayal produces a sense of victimization
External to self, caused by others
My pain is someone else’s fault
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Implications for Nursing
Mental Health Assessment
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Nurses need to “stop being afraid” of asking
about religious/spiritual issues
Understand the importance of religious/
spirituality in patient’s lives, “do not gloss over
the issue”
Sequencing of value/belief question(s) as it
relates to patient’s strength
Ask what brings meaning/purpose to life?
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How Does a Soldier Return?
Homer’s The Odyssey – returning is
difficult and a long struggle
 Mosaic Law: Numbers 31:19-20
 Native American cleansing ceremony
 American way: “Suck it up, buttercup…”
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There is a Way Back…
1. Connection – begins with strong therapeutic relationship
2. Plan – accepting group, successive steps forward - The Combat Trauma
Healing Manual
3. Emotional Reliving – “Leaning into the wind”
4. Introspection – at the deepest level of self, who am I?
5. Conversations with God/Higher Power
- Disclose the transgression, if any (confession)
- Articulate how one feels about self (guilt, shame, victimization)
- Acknowledge what should be the outcome (justice, judgment,
personal responsibility)
- Ask for forgiveness based on God’s mercy and grace (repentance)
- Grant forgiveness to those who wronged you (letting go victimhood)
- Receive reassurance based on God’s promises (grace, forgiveness)
- Plan for reparations where able (fruits of repentance)
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There is a Way Back…
Continued
6. Healing ritual
7. Cultivate goodness – art, beauty, peace, harmony
8. Re-connect – family, friends, church community
9. Plan for the long haul – rarely a “quick fix”
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Case Studies
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RESPONSES
• Patient in ICU
“ Felt God had abandoned him”
• Patient in Inpatient Mental Health
“Angry with God”
• Patient in ICU
“God did not save his teenage daughter who had
cancer, so patient feels forgotten by God”
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Final Comment
“My sense is that this is a fundamentally religious
issue. It’s possible to package it as a mental
health issue, but I think we lose out. Even people
who have had good secular treatments for their
trauma still feel a need for the religious dimension
of it. I don’t think as a society we are offering it.”
Jonathan Shay, author of Achilles in Vietnam (1995)
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References
Adsit, Chris. The Combat Trauma Healing Manual – Christ Centered Solutions for Combat Trauma.
Newport News, VA: Military Ministry Press, 2008.
Cipolla, Benedicta, Healing the Wounds of War, Religion & Ethics NewsWeekly, 2007.11.30.
Drescher, Kent; Foy, David; Kelly, Caroline; Leshner, Anna; Schultz, Kerrie; Litz, Brett. An Exploration of
the Viability and Usefulness of the Construct of Moral Injury in War Veterans, in
Traumatology. Published online 10 March 2011.
Hoge, Charles W. Once a Warrior Always a Warrior – Navigating the Transition from Combat to Home
– Including Combat Stress, PTSD, and mTBI. Guilfore, Conn: Globe Pequot Press, c. 2010.
Litz, Brett; et. Al.; Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention
Strategy, in Clinical Psychology Review, 2009.07.003.
Maguen, Shira and Litz, Brett. Moral Injury in Veterans of War, in PTSD Research Quarterly, Vol 23, No. 1,
c. 2012.
Marlantes, Karl. What It Is Like to Go to War. New York: Atlantic Monthly Press, c. 2011.
Shay, Jonathan. Achilles in Vietnam – Combat Trauma and the Undoing of Character. New York:
Simon & Schuster, c. 1994.
Tick, Edward. War and the Soul – Healing Our Nation’s Veterans from Posttraumatic Stress Disorder.
Quest Books, 2005.
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