Moral Injury Is The 'Signature Wound' Of Today's Veterans

Interview with David Wood
NPR
Originally posted November 11, 2014

Here is an excerpt:

On the best therapy for treating this "bruise on the soul"

The biggest thing that [the veterans] told me was that they're carrying around this horrible idea that they are bad people because they've done something bad and they can't ever tell anybody about it — or they don't dare tell anybody about it — and may not even be able to admit it to themselves.

One of the most healing things they have found is to stand in a group of fellow veterans and say, "This is what happened. This is what I saw. This is what I did," and to have their fellow veterans nod and say, "I hear you. I hear you." And just accept it, without saying, "Well, you couldn't help it," or, "You're really a good person at heart."

But just hearing it and accepting it — and not being blamed or castigated for whatever it was that you're feeling bad about. It's that validating kind of listening that is so important to all the therapies that I've seen.

The entire article is here.

Minneapolis VA studies invisible scars from combat

By Jeremy Olson
The Star Tribune
Updated August 11, 2014

Here is an excerpt:

A study of survey results for 814 Minnesota National Guard members who served in Iraq over the past decade showed that those who experienced moral injury had higher levels of depression and post-traumatic stress disorder (PTSD).

Moral injury generally refers to any type of guilt, shame, or depression that arises from actions that may have violated deeply held beliefs. But for this study, which was presented at the Minneapolis VA Medical Center last month, soldiers met the criteria if they killed in combat, felt their actions were unforgivable, and believed that God had abandoned them.

The lack of resiliency among soldiers who met this definition was alarming, said Dr. Irene Harris, the VA psychologist leading the research. “Basically, [they feel] at my spiritual functioning level, I don’t think I belong here in the world. I’m not worth it. I have a sense that I should not be here.’’

The entire article is here.

Podcast Episode 7: The Moral Self, Moral Injury, and Moral Emotions addresses the moral self and moral injury related to PTSD.

Episode 7: The Moral Self, Moral Injury, and Moral Emotions

In this episode, John interviews Dr. Nina Strohminger about moral psychology and her research on the moral self and moral emotions.  While they discuss her research about the moral self and moral emotions, the discussion leads to clinical examples related to values in psychotherapy, moral injury and other conditions treated by psychologists.  John and Nina also exchange ideas on emotions in decision-making.

At the end of this podcast, the listener will be able to:

1. Describe the moral self,
2. Explain moral injury and how it applies to psychotherapy,
3. Identify how emotions are important to decision-making.

Find this podcast in iTunes

Click here to purchase 1 APA-approved Continuing Education credit

Or listen directly here.

Resources

Nina Strohminger's website

The Essential Moral Self 

Nina Strohminger and Shaun Nichols

Divergent Effects of Positive Emotions on Moral Judgment 

Nina Strohminger, Richard L. Lewis, and David D. Meyer

Morality in Psychotherapy

John Gavazzi and Sam Knapp

Morality, Disgust and Countertransference in Psychotherapy
John Gavazzi and Sam Knapp

Moral Injury in Veterans of War

Shira Maguen and Brett Litz

Scrupulosity: Where OCD Meets Religion, Faith and Belief
Kevin Foss, The OCD Center of Los Angeles

Moral Injury

By David Wood
Huffington Post
Originally published March 17, 2014

Here is an excerpt:

It is what experts are coming to identify as a moral injury: the pain that results from damage to a person’s moral foundation. In contrast to Post-Traumatic Stress Disorder, which springs from fear, moral injury is a violation of what each of us considers right or wrong. The diagnosis of PTSD has been defined and officially endorsed since 1980 by the mental health community, and those suffering from it have earned broad public sympathy and understanding. Moral injury is not officially recognized by the Defense Department. But it is moral injury, not PTSD, that is increasingly acknowledged as the signature wound of this generation of veterans: a bruise on the soul, akin to grief or sorrow, with lasting impact on the individuals and on their families.

Moral injury raises uncomfortable questions about what happens in war, the dark experiences that many veterans have always been reluctant to talk about. Are the young Americans who volunteer for military service prepared for the ethical ambiguity that lies ahead? Can they be hardened against moral injury? Should they be?

The entire article is here.

There will be an upcoming podcast on morality and the moral self.

Defining The Deep Pain PTSD Doesn't Capture

By Martha Bebinger
WBUR
June 24, 2013

An estimated 22 veterans kill themselves in the U.S. each day. And suicide among men and women on active duty hit a record high last year — 349. As veterans and researchers try to figure out why, there’s growing interest in a condition known as “moral injury,” or wounds to a veteran’s spirit or soul from events that “transgress deeply held moral beliefs and expectations.”

The concept has helped former Marine Corps Capt. Tyler Boudreau understand years of pain that medication and therapy for PTSD didn’t address. He tells his story, somewhat reluctantly, from the living room of his blue clapboard home in Northampton, Mass.

‘This Is What Occupation Looks Like’

Boudreau arrived in Iraq in the March of 2004 at the age of 33 shortly before four American contractors were killed in Fallujah. His unit moved into position for a planned assault on the city.

“We were always getting shelled, constant rocket and mortar attacks,” Boudreau explained. “An IED, the roadside bomb, blew up right next to my vehicle and I was involved in some firefight that was pretty, you know, pretty intense.”

The constant shelling wore on Boudreau. But the daily duties of war, what he did to Iraqis, also took a toll on him.

The entire story is here.

Spiritual Care and Moral Injury in Service Members

By George F. Handzo
Caring Connections
Volume 10, Number 1
Winter 2013

Here are some excerpts:

It is important to note that moral injury has been widely discussed in several contexts, including sexual assault and the provision of health care—the latter being mainly in the nursing literature. While there are significant overlaps in cause, symptoms and spiritual interventions, moral injury in the military is focused on and arises from the particular context of the service member’s involvement in combat. In the military, moral injury is most often talked about as a subcategory of PTSD although, as I will discuss below, this can be a misleading characterization.

Definitions

Moral Injury:

The behavioral, cognitive, and emotional aftermath of unreconciled severe moral conflict, withdrawal, and self-condemnation. It closely mirrors re-experiencing, avoidance, and emotional numbing symptoms of PTSD.   Unlike life-threat trauma, moral injury may also include: self-harming behaviors, such as poor self-care, alcohol and drug abuse, severe recklessness, and parasuicidal behavior, self-handicapping behaviors, such as retreating in the face of success or good feelings, and demoralization, which may entail confusion, bewilderment, futility, hopelessness, and self-loathing. (Litz, B, et al, 2009)

Moral Distress:

The painful psychological disequilibrium that results from recognizing the ethically appropriate action, yet not taking it, because of such obstacles as lack of time, supervisory reluctance, an inhibiting power structure, institution policy, or chain of command considerations (Corley et al., 2001) (Thus, moral distress in this context is largely a symptom of moral injury).

PTSD:

The result of exposure to events so overwhelmingly stressful and extraordinary that anyone who experiences them would be distressed. In the experience of the ma, the person usually fears for his or her life or the lives of others. This triggering traumatic event overwhelms the person’s ability to respond or cope adequately. For normal diagnostic purposes, PTSD has four components – the stressor, re-experiencing, avoidance, and hyper-arousal.   All four components must be present for a diagnosis of PTSD.

The entire article is here.

Thanks to Gary Schoener for the article.

The Winter Issue of Caring Connections is entitled Light in the Darkness: Hope, Resilience and Moral Injury and has several articles related to moral injury.

War zone killing: Vets feel 'alone' in their guilt

By PAULINE JELINEK
Associated Press
Originally published February 22, 2013

A veteran of the wars in Iraq and Afghanistan, former Marine Capt. Timothy Kudo thinks of himself as a killer — and he carries the guilt every day.

"I can't forgive myself," he says. "And the people who can forgive me are dead."

With American troops at war for more than a decade, there's been an unprecedented number of studies into war zone psychology and an evolving understanding of post-traumatic stress disorder. Clinicians suspect some troops are suffering from what they call "moral injuries" — wounds from having done something, or failed to stop something, that violates their moral code.

Though there may be some overlap in symptoms, moral injuries aren't what most people think of as PTSD, the nightmares and flashbacks of terrifying, life-threatening combat events. A moral injury tortures the conscience; symptoms include deep shame, guilt and rage. It's not a medical problem, and it's unclear how to treat it, says retired Col. Elspeth Ritchie, former psychiatry consultant to the Army surgeon general.

The entire story is here.

Tending to Veterans’ Afflictions of the Soul

By Samuel J. Freedman
The New York Times
Originally published January 13, 2013

Here are some excerpts:

Moral injury might best be defined as an affliction of the soul, as distinct from a specific mental health condition like post-traumatic stress disorder. It arises, to speak in a very broad way, from the way a combatant’s actions in war seem to violate and thus undermine the most deeply held moral beliefs.

Ms. Brock did not formulate the concept of moral injury, which is attributed to the clinical psychiatrist Jonathan Shay. In books like “Achilles in Vietnam,” Dr. Shay has traced moral injury back as far as the Trojan War. But for Ms. Brock and her colleagues, the kind of counterinsurgency wars America has fought in Iraq and Afghanistan has left soldiers uniquely vulnerable to moral injury.

“There’s no good choice,” she said. “If you’re looking at a kid on the side of the road with something in his hand, if it’s a grenade and he throws it and kills someone in your unit, you’ve failed your comrade. But if it’s a rock, you’ve just shot a kid with a rock.
“If you’re praying that your company gets out or that your best friend isn’t shot, and it doesn’t turn out that way, it can collapse your whole moral system. It feels like God abandoned you.”

Her description closely matched that of Michael Yandell, 28, a student at the Brite seminary who worked on a bomb disposal team during the Iraq war. “Most deeply, it’s a loss of confidence in one’s own ability to make a moral judgment with any certainty,” he said. “It’s not that you lose your ability to tell right from wrong, but things don’t seem so clear any more. For me, it’s whether or not what I did, did any good.”

Ms. Brock’s affinity for veterans, and her knowledge of their suffering, has long, deep roots. Her father, Roy Brock, was taken prisoner during World War II and underwent electroshock treatments after liberation for his psychological distress. He later served two tours in Vietnam as a medic, enduring the deaths not only of countless soldiers but the local translator he had befriended.

The entire story is here.