Download Chaplain Kerry Haynes, D. Min., M.Div

PTSD AND MORAL INJURY
IN SERVICE MEMBERS
AND VETERANS
Chaplain Kerry Haynes
D.Min., M.Div., BCC/MH
Mental 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
authority
3. 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
MORAL INJURY
• Anxiety & fear
• Guilt & shame
• Diagnosis in
DSM-5
• Dimensional
problem
• Does not require
moral injury
• Does not require
PTSD
SYMPTOMS OVERLAP
Moral Injury
PTSD
Focus on fearbased
responses
Treatment
based on
exposure and
re-evaluation
of cognitions
Avoidance
Reexperiencing
Grief/Loss
Hypervigilance
Guilt/Shame
Higher sense of
alienation and
purposelessness
Treatment
addresses moral
conflict and selfcondemnation
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 CARE
Sensitivity 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 amends
Ronnie 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 TREATMENTS
Cognitive-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 TRIAL
Impact 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 realtime 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. INDIVIDUAL
INDIVIDUAL
• Less threatening
initially (with warm,
accepting chaplain)
GROUP
• More threatening
initially (unless safety
in numbers)
• Tailored to unique
needs
• Less tailored to
unique needs
• More time intensive
• Less time intensive
• Less community
building
• More community
building
GROUP OPTIONS
OPEN
• 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
• Providence
• Nashville
• Mountain Home
• Portland
• Philadelphia
• Loma Linda
• 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 ([email protected])
• Dr. Zenon Culverhouse ([email protected])
QUESTIONS/COMMENTS?
Kerry Haynes, D.Min., BCC/MH
Mental Health Chaplain
San Antonio VA
210-617-5300, ext. 13317
[email protected]
BIBLIOGRAPHY
Brock, 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): 5463.
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.
BIBLIOGRAPHY
Gray, 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.
BIBLIOGRAPHY
Kim, 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).
BIBLIOGRAPHY
Litz, 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.
BIBLIOGRAPHY
Meagher, 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.
BIBLIOGRAPHY
Riek, 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).
BIBLIOGRAPHY
Sherman, 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 Posttraumatic Stress Disorder. Wheaton: Quest Books, 2005.
_____. Warrior’s Return: Restoring the Soul After War. Boulder: Sounds
True, 2014. Worthington, Everett. “Self-condemnation and selfforgiveness.” 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.