War Wounds That Time Alone Can't Heal

by Jane E. Brody
The New York Times
Originally published June 6, 2016

Here are two excerpts:
Therapists both within and outside the Department of Veterans Affairs increasingly recognize moral injury as the reason so many returning vets are self-destructive and are not helped, or only partly helped, by established treatments for PTSD.

Moral injury has some of the symptoms of PTSD, especially anger, depression, anxiety, nightmares, insomnia and self-medication with drugs or alcohol. And it may benefit from some of the same treatments. But moral injury has an added burden of guilt, grief, shame, regret, sorrow and alienation that requires a very different approach to reach the core of a sufferer’s psyche.

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Therapists who study and treat moral injury have found that no amount of medication can relieve the pain of trying to live with an unbearable moral burden. They say those suffering from moral injury contribute significantly to the horrific toll of suicide among returning vets — estimated as high as 18 to 22 a day in the United States, more than the number lost in combat.

The article is here.

Is Gun Violence a Public Health Crisis?

Science Friday Podcast
Ira Flatow is the Host and Executive Producer

On Wednesday, a mass shooting in San Bernardino, California left 14 people dead, making it one of the deadliest in modern American history. In fact, there have been more mass shootings than there have been days in 2015 so far. Of course, gun violence in the United States isn’t restricted to mass shootings—firearm homicides and suicides far outpace the number of mass-shooting fatalities. Taken together, an estimated 32,000 people die as a result of gun violence in the United States annually, and an additional 180,000 to 190,000 people are injured, says Sandro Galea. He’s the dean of Boston University’s School of Public Health and one of a number of researchers calling for firearm deaths to be treated as a public health issue. Another is Garen Wintemute, of the UC Davis School of Medicine, who has done extensive research on the effects of access to guns. Wintemute and Galea join Ira to discuss why they see gun violence as a public health issue and what research must be done and steps taken to address the problem.

The podcast is here.

Implanting and Erasing Memories: Life-Changing, or Taking Science Too Far?

By Jordan Gaines Lewis
Gaines, on the Brain
Originally published November 9, 2015

Here is an excerpt:

But what if doctors and researchers could attack PTSD at the source: actually implanting or erasing specific memories in a person's brain?

It may sound like science fiction — not unlike Lord Voldemort luring Harry Potter to the Ministry of Magic by creating false images in Harry's mind, or the entire premise of the movie Inception — but science is actually getting close. In mice, neuroscientists have found ways to not only identify the location of certain memories, but to actually manipulate those memories.

But can we do this in humans — in patients with PTSD? And perhaps the bigger question: should we?

The entire blog post is here.

Healing a Wounded Sense of Morality

Many veterans are suffering from a condition similar to, but distinct from, PTSD: moral injury, in which the ethical transgressions of war can leave service members traumatized.

By Maggie Puniewska
The Atlantic
Originally published July 3, 2015

Here are two excerpts:

Identifying moral injury can be tricky for two reasons: First, it’s easily mistaken for PTSD, which shares many of the same symptoms. And second, because veterans may feel too ashamed to talk about their moral infractions, therapists might not even know to look for the signs of moral injury at all, says Joseph Currier, an assistant professor of psychology at the University of South Alabama. To help therapists better understand how to diagnose the condition, he and several colleagues have developed a 20-item questionnaire that screens patients for moral injury, asking patients to rate their agreement with statements like “I did things in war that betrayed my personal values” and “I made mistakes in the war zone that led to injury and death.”

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But healing isn’t just confined to the individual. Emotions that guide morality, Currier explains, are rooted in social relationships:  “The function of guilt is to reconcile a potentially damaged social bond, whereas with shame, the reaction is to withdraw so the social group can preserve its identity,” he says.   For many veterans, therefore, recovery from moral injury depends in part on the civilian communities to which they return. “A part of feeling betrayed or distrusted or guilty by the practices of war is feeling alienated. It’s feeling like you can’t share your experiences because people will judge you or won’t understand,” Sherman says.

The entire article is here.

Healing Moral Wounds of War

Religion and Ethics News Weekly
PBS
Originally posted June 26, 2015

In her book Afterwar: Healing the Moral Wounds of Our Soldiers, Georgetown University philosophy professor Nancy Sherman argues that many of the 2.6 million U.S. service members returning from our wars in Afghanistan and Iraq suffer from complex moral injuries that are more than post-traumatic stress and that have to do with feelings of guilt, anger, and “the shame of falling short of your lofty military ideals.” Citizens have “a sacred obligation,” says Sherman, to morally engage with those who have fought in our name and who feel moral responsibility for traumatic incidents they experienced. Managing editor Kim Lawton interviews Sherman about the moral aftermath of war and visits a former Marine and his wife to talk about the healing that comes through listening, trust, hope, and moral understanding.

Immune from Cyber-fire? The Psychological and Physiological Effects of Cyberwar

By Michael L. Gross, Dapna Canetti, & Israel Waismel-Manor
In: Binary Bullets: The Ethics of Cyberwarfare.
Edited by Fritz Allhoff, Adam Henschke, and Bradley Jay Strawser.
Oxford: Oxford University Press, forthcoming

Here is an excerpt:

Following an overview that describes the challenge that cyber-operations pose for the principle of noncombatant immunity, the following sections map out and analyze the harms of cyberwarfare. Consider, first, physiological harm.  Although no person has lost his life or suffered any kind of physical injury from a cyber-attack to date, the literature is replete with scenarios of death and devastation.  These come in the course of cyber-attacks on vital infrastructures that disrupt air and
rail transportation or poison water supplies. In many ways, these are similar to the consequences of conventional war. For the most part, however, modern cyberwarfare causes no physical injury. As a result, one may reasonably ask whether noncombatants enjoy protection from cyber-attacks that disrupt telecommunications, disable social media, or destroy, disclose or steal financial data and personal information. The answer hinges upon the psychological harm that victims suffer, particularly if belligerents target civilians and civilian infrastructures directly.  Extrapolating from studies of cyber-bullying, identity theft and ordinary burglary, and building upon the effects of simulated cyber-terrorism in the laboratory, we explore the psychological harms of cyberwarfare. Cyberwarfare is not benign but causes stress, anxiety and fear. Such mental suffering threatens to disrupt routine life, impair educational and workplace performance, impact significantly on the poor
and elderly, and increase public pressure on the government to act. Although most forms of psychological suffering are not as intense, prolonged or irreversible as bodily injury or loss of life, our analysis suggests that the psychological harm of cyberwar can affect well-being nonetheless.

The entire article is here.

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.

If Trauma Victims Forget, What Is Lost to Society?

A pill to dampen memories stirs hope and worry.

By Emily Anthes
Nautilus
Originally posted July 17, 2014

Here is an excerpt:

However, promising studies have also stirred controversy, with some bioethicists warning that memory-dulling drugs could have profound, unintended consequences for our psyches and our society. The debate is raising tricky questions about what—and who—memory is for. The European Union’s highest court recently ruled that, at least when it comes to the Internet, we all have the “right to be forgotten” for things no longer relevant. Do we also have the right to forget?

The entire article is here.

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.

Gruesome case videos became too much for top psychiatrist

Chris Cobb, Postmedia News | Originally published 11/11/13

Dr. John Bradford’s mental breakdown hit without warning less than half an hour after he watched Canadian Air Force colonel Russell Williams sexually assaulting two young women whom he would later kill.

During his long and distinguished career as a doctor and teacher, the internationally renowned forensic psychiatrist had become skilled at emotionally detaching himself from all manner of horrendous images.

He was relatively comfortable sitting across a table from the likes of notorious sex killers Paul Bernardo, Robert (Willie) Pickton and Williams.

And like all professionals in his line of work, Dr. Bradford was trained to focus on the killer, not the crime. His job is to get inside a killer’s mind, not to pass judgment on the severity or brutality of the killer’s actions.

The entire article is here.

Thanks to Gary Schoener for this article.

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.

Military says it's focusing on suicide prevention

By Mike Urban
The Reading Eagle
Originally published November 12, 2012


Fewer of America's troops are heading into combat with the war in Iraq over and the war in Afghanistan nearing a close.

But the demand for mental health care among active duty personnel is increasing, in part because combat has left many in need of help, and because the military is doing more to treat its mentally ill troops, Department of Defense officials said.

Suicide prevention has become one of the military's most urgent concerns, and treatment of post-traumatic stress disorder within the military has come a long way in recent years, said Defense Department spokeswoman Cynthia O. Smith.

"We are committed to taking care of our people, and that includes doing everything possible to prevent suicides in the military," she said.

To reduce the long-standing military stigma surrounding mental health problems, the defense department urges commanders to support those in need of care, she said.

The entire story is here.

Panel calls for annual PTSD screening

By Kevin Freking
The Associated Press
Originally published July 13, 2012

The Institute of Medicine recommended Friday that soldiers returning from Iraq and Afghanistan undergo annual screening for post-traumatic stress disorder and that federal agencies conduct more research to determine how well the various treatments for PTSD are working.

Of the 2.6 million service members deployed to Iraq and Afghanistan, it's estimated that 13 percent to 20 percent have symptoms of PTSD.

Federal agencies have increasingly dedicated more resources to screen and treat soldiers, but considerable gaps remain, according to the Institute of Medicine, an independent group of experts that advises the federal government on medical issues. Its recommendations often make their way into laws drafted by Congress and policies implemented by federal agencies.

The entire story is here.

Parity for Patriots: The mental health needs or military personnel, veterans and their families

The National Alliance on Mental Illness released a report entitled Parity for Patriots: The Mental Health Needs of Military Personnel, Veterans and their Families.  Here is a section of the report that is particularly important.

"The U.S. Department of Defense must move more forcibly to end discrimination associated with invisible wounds of war. Reducing the stigma of mental illness will enhance opportunities to deliver prompt, effective treatment to military service members and families who live with PTSD, depression and other mental health conditions. Examples of immediate steps that can be taken to eliminate stigma and barriers to seeking help include:

• Military leader accountability for stigma and suicide: Military leaders throughout the chain of command should be required to focus on preventable psychological injuries and deaths, which should be part of their efficiency reporting process. Suicides are preventable just as are the heat and cold injuries of service members for which leaders are routinely relieved of command.
• Purple Heart for psychological wounds: Posttraumatic stress and other mental health injuries, that are the result of hostile action, including terrorism, should be eligible for award of the Purple Heart with the same level of appreciation and recognition as those awarded to warriors with visible wounds.

The Veterans Health Administration must increase service capacity by expanding provider networks to include community mental health agencies and private practitioners. The VHA should monitor the degree to which contract providers accept veterans and families as clients and should adjust networks to make care available when and where it is needed. Ongoing training in military-informed mental health treatment should be a basic requirement for contract providers. Improved distance delivery through technology should be implemented to remove the travel burden from veterans and improve the use of professional care giver time."

The entire report is here.

Please remember our military service personnel on this holiday.

Pentagon Chief Orders Review of Mental Diagnoses

By Donna Cassata
ABCNews.com
Originally published June 13, 2012

Under questioning from a Senate panel on Wednesday, Panetta disclosed that he had asked the Air Force and Navy, which includes the Marine Corps, to follow the lead of the Army in launching an independent study of how it evaluates soldiers with possible post-traumatic stress disorder. Panetta's answer marked the first time that the Pentagon chief had said publicly that he had requested the review by all the services.

Defense Secretary Leon Panetta

The Army review was prompted in part by reports that the forensic psychiatry unit at Madigan Army Medical Center at Joint Base Lewis-McChord in Washington state may have reversed PTSD diagnoses based on the expense of providing care and benefits to members of the military. In recent years, the number of PTSD and traumatic brain injury cases has increased significantly as the Iraq war drew to a close after nearly a decade and the Afghanistan conflict enters its second decade.

Th entire story is here.

Army to Review Its Handling of Psychiatric Evaluations

By James Dao
The New York Times
Originally published on May 16, 2012

The Army said Wednesday that it had ordered a service-wide review of how its doctors diagnose psychiatric disorders, indicating that complaints about unfair diagnoses at a sprawling base in Washington State have been echoed on installations around the country.

The review, announced jointly by the Army secretary, John M. McHugh, and chief of staff, Gen. Raymond T. Odierno, will focus on whether consistent and accurate diagnoses are being issued by the disability evaluation system, which determines whether injured soldiers are fit to remain on duty.

Concerns about the system emerged last fall after soldiers at Joint Base Lewis-McChord in Tacoma told Senator Patty Murray, a Democrat of Washington, that their diagnoses of post-traumatic stress disorder had been changed by doctors at Madigan Army Medical Center to lesser conditions. The soldiers asserted that the changes were done to save the Army money.

The entire story is here.