Archive for Veteran

Moral Injury in the Context of War (U.S. Dept. of VA)

Posted in Moral Injury with tags , , , , , , , on 4 December 2012 by Daryl Densford

Copied without edit for educational purposes from U.S. Department of Veterans Affairs, National Center for PTSD.

.

Shira Maguen, PhD and Brett Litz, PhD

.

What is moral injury?

Like psychological trauma, moral injury is a construct that describes extreme and unprecedented life experience including the harmful aftermath of exposure to such events. Events are considered morally injurious if they “transgress deeply held moral beliefs and expectations” (1). 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.

Moral injury in war

In the context of war, moral injuries may stem from direct participation in acts of combat, such as killing or harming others, or indirect acts, such as witnessing death or dying, failing to prevent immoral acts of others, or giving or receiving orders that are perceived as gross moral violations (2). The act may have been carried out by an individual or a group, through a decision made individually or as a response to orders given by leaders.

Examples:

  • Unintentional Errors: Military personnel are well trained in the rules of engagement and do a remarkable job making life or death decisions in war; however, sometimes unintentional error leads to the loss of life of non-combatants, setting the stage for moral injury.
  • Transgressive Acts of Others: Service members can be morally injured by the transgression of peers and leaders who betray expectations in egregious ways.

What is the aftermath of moral injury?

In terms of the aftermath of moral injuries, transgressive acts may result in highly aversive and haunting states of inner conflict and turmoil. Emotional responses may include:

  • shame, which stems from global self-attributions (e.g., “I am an evil terrible person; I am unforgivable”)
  • guilt
  • anxiety about possible consequences
  • anger about betrayal-based moral injuries

Behavioral manifestations of moral injury may include:

  • anomie (e.g., alienation, purposelessness, and/or social instability caused by a breakdown in standards and values)
  • withdrawal and self-condemnation
  • self-harming (e.g., suicidal ideation or attempts)
  • self-handicapping behaviors (e.g., alcohol or drug use, self-sabotaging relationships, etc.)

Additionally, moral injury has been posited to result in the re-experiencing, emotional numbing, and avoidance symptoms of PTSD. In addition to grave suffering, these manifestations of moral injury may lead to an array of anti-social behaviors, under- or unemployment, and failed or harmed relationships with loved ones and friends.

Does killing cause moral injury?

Several studies demonstrate an association between killing in war and mental and behavioral health problems, which may be proxies for moral injury (3-8).

For example:

  • Across eras (e.g., Vietnam, Gulf War, Operation Iraqi Freedom (OIF)) those who kill in war are at greater risk for a number of mental health consequences and functional difficulties, including PTSD, after accounting for a number of demographic variables and other indicators of combat exposure (3-5).
  • In returning OIF Veterans, even after controlling for combat exposure, taking another life was a significant predictor of PTSD symptoms, alcohol abuse, anger, and relationship problems (3).
  • Vietnam Veterans who reported killing were twice as likely to report suicidal ideation as those who did not, even after accounting for general combat exposure, PTSD and depression diagnoses (9). In OIF Veterans, the relationship between killing and suicidal ideation was mediated by PTSD and depression symptoms (10).

Although killing may be a precursor to moral injury, it is important to note that not all killing in war results in adverse outcomes for military personnel. As outlined in the section above, certain elements need to be present for moral injury to occur, including a perceived transgression that goes against individual of shared moral expectations.

For example, a military member who kills an enemy combatant in self-defense may perceive that the death was justified. If however, a civilian was perceived to be armed and consequently killed, with military personnel later discovering that the individual was in fact unarmed, this may set the stage for the development of moral injury.

Are moral injury and PTSD the same?

Although more research is needed to answer this question, at present, although the constructs of PTSD and moral injury overlap, each has unique components that make them separable consequences of war and other traumatic contexts.

  • PTSD is a mental disorder that requires a diagnosis. Moral injury is a dimensional problem – there is no threshold for the presence of moral injury, rather, at a given point in time, a Veteran may have none, or mild to extreme manifestations.
  • Transgression is not necessary for a PTSD diagnosis nor does the PTSD syndrome sufficiently capture moral injury (shame, self-handicapping, guilt, etc.).

Consequently, it is important to assess mental health symptoms and moral injury as separate manifestations of war trauma to form a comprehensive clinical picture, and provide the most relevant treatment.

What can be done to treat moral injury in Veterans of war?

Existing evidence-based treatments (EBTs) for PTSD supported by the VA, namely Prolonged Exposure Therapy (PE) and Cognitive Processing Therapy (CPT) may sufficiently address the moral wounds of war in service members and Veterans.

However, because these therapies do not explicitly consider the unique clinical issues that arise from combat losses and experiences that are morally compromising, and because extant EBTs were primarily developed to target posttraumatic conditioned fear memories and related beliefs among victims of trauma, they may not be sufficient for service members and Veterans who suffer from the moral injuries of war, especially killing-based transgressions.

Current research for treatment of moral injury

In service of broadening the discourse, we generated and are currently testing interventions that specifically target moral injury among Veterans of war.

The first intervention is a six-session module called Impact of Killing in War (IOK), developed to augment existing EBTs for PTSD (i.e., IOK is used in conjunction with existing EBT for PTSD interventions, in those who have conflict related to killing in war). ). Pilot testing is currently underway. IOK contains the following elements, presented within a cognitive-behavioral framework:

  • education about the complex interplay of the biopsychosocial aspects of killing in war that may cause inner conflict and moral injury
  • identification of meaning elements and cognitive attributions related to killing in war
  • self-forgiveness (which entails cognitive therapy and for some the promotion of spirituality or faith-based religious practices)
  • making amends tailored to the individual (this may include writing forgiveness letters and an action plan to start the process of making amends)

The second treatment is called Adaptive Disclosure (AD), an eight-session intervention that takes into account unique aspects of the phenomenology of military service in war in order to address difficulties such as moral injury and traumatic loss that are not explicitly addressed in extant EBTs (11). At its core, AD is an experiential exposure-based approach.

  • Exposure is used to uncover core features of focal combat and operational trauma and as a means of articulating the meaning and implication of these events.
  • If the focal combat event is fear and life-threat-based, exposure is the sole approach.
  • If the focal trauma is loss-based, patients are also asked to have an imaginary emotionally evocative real-time dialogue with the lost person.
  • For moral injury, patients are guided through a real-time dialogue with a forgiving and compassionate moral authority about the transgression.

The added experiential strategies are designed to expose patients to corrective information about the meaning and implication of their war experiences. In an open trial, 44 Marines received AD in garrison. Participating Marines demonstrated significant reductions in PTSD symptoms, depression symptoms, and negative posttraumatic appraisals; AD was also associated with increases in posttraumatic growth (12).

References

  1. Litz, B.T., Stein, N., Delaney, E., Lebowitz, L., Nash, W.P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695-706.
  2. Drescher, K., Foy, D., Kelly, C., Leshner, A., Schutz, A., & Litz, B.T. (2011). An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology, 17, 8-13.
  3. Maguen, S., Metzler, T.J., Litz, B.T., Seal, K.H., Knight, S.J., & Marmar, C.R. (2009). The impact of killing in war on mental health symptoms and related functioning. Journal of Traumatic Stress, 22, 435-443.
  4. Maguen, S., Lucenko, B.A., Reger, M.A., Gahm, G.A., Litz, B.T., Seal, K.H., Knight, S.J., & Marmar, C.R. (2010). The impact of reported direct and indirect killing on mental health symptoms in Iraq War veterans. Journal of Traumatic Stress, 23, 86-90.
  5. Maguen, S., Vogt, D.S., King, L.A., King, D.W., Litz, B.T., Knight, S.J., & Marmar, C.R. (2010, October 4).The impact of killing on mental health symptoms in Gulf War veterans. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. doi: 10.1037/a0019897.
  6. Fontana, A., Rosenheck, R. & Brett, E. (1992). War zone traumas and posttraumatic stress disorder symptomatology. Journal of Nervous and Mental Disease, 180, 748-755.
  7. MacNair, R.M. (2002). Perpetration-inducted traumatic stress in combat veterans.Peace and Conflict: Journal of Peace Psychology, 8, 63-72.
  8. Fontana, A. & Rosenheck, R. (1999). A model of war zone stressors and posttraumatic stress disorder. Journal of Traumatic Stress, 12, 111-26.
  9. Maguen, S., Metzler, T.J., Bosch, J., Marmar, C.R., Knight, S.J., & Neylan, T.C. Killing in combat is an independent predictor of suicidal ideation. Manuscript under review.
  10. Maguen, S., Luxton, D.D., Skopp, N.A., Gahm, G.A., Reger, M.A., Metzler, T.J., & Marmar, C.R. (2011). Killing in combat, mental health symptoms, and suicidal ideation in Iraq War Veterans. Journal of Anxiety Disorders, 25, 563-567.
  11. Steenkamp, M., Litz, B. T., Gray, M., Lebowitz, L., Nash, W., Conoscenti, L., Amidon, A., & Lang, A., (2011). A brief exposure-based intervention for service members with PTSD. Cognitive and Behavioral Practice, 18, 98-107.
  12. Gray, M.J., Schorr, Y., Nash, W., Lebowitz, L., Amidon, A., Lansiung, A. Maglione, M., Lang, A.J., Litz, B.T. (in press). Adaptive Disclosure: An open trial of a novel exposure-based intervention for service members with combat-related psychological stress injuries. Behavior Therapy.
Date Created: 12/23/2011 See last Reviewed/Updated 04/20/2012
.
Copied without edit for educational purposes from U.S. Department of Veterans Affairs, National Center for PTSD.
Advertisements

“Moral Injury” and Modern War (The American Conservative)

Posted in Moral Injury with tags , , , , , , , on 4 December 2012 by Daryl Densford

This article is copied without edit for educational purposes from The American Conservative.

The psychological wounds of PTSD are now recognized —but what about the ethical wounds of training to kill?

(Via TomDispatch.com.)  By NAN LEVINSON • June 28, 2012

“PTSD is going to color everything you write,” came the warning from a stepmother of a Marine, a woman who keeps track of such things.  That was in 2005, when post-traumatic stress disorder, a.k.a. PTSD, wasn’t getting much attention, but soon it was pretty much all anyone wrote about.  Story upon story about the damage done to our guys in uniform — drinking, divorce, depression, destitution — a laundry list of miseries and victimhood. When it comes to veterans, it seems like the only response we can imagine is to feel sorry for them.Victim is one of the two roles we allow our soldiers and veterans (the other is, of course, hero), but most don’t have PTSD, and this isn’t one of those stories.

Civilian to the core, I’ve escaped any firsthand experience of war, but I’ve spent the past seven years talking with current GIs and recent veterans, and among the many things they’ve taught me is that nobody gets out of war unmarked.  That’s especially true when your war turns out to be a shadowy, relentless occupation of a distant land, which requires you to do things that you regret and that continue to haunt you.

Theoretically, whole countries go to war, not just their soldiers, but not this time.  Civilian sympathy for “the troops” may be just one more way for us to avoid a real reckoning with our last decade-plus of war, when the hostilities in Iraq and Afghanistan have shown up on the average American’s radar only if somebody screws up or noticeable numbers of Americans get killed.  The veterans at the heart of this story — victims, heroes, it doesn’t matter — struggle to reconcile what they did in those countries with the “service” we keep thanking them for.  We can see them as sick, with all the stigma, neediness, and expense that entails, or we can recognize them as human beings, confronting the morality of what they’ve done in our name and what they’ve seen and come to know — even as they try to move on.

Sacred Wounds, Moral Injuries

Former Army staff sergeant Andy Sapp spent a year at Forward Operating Base Speicher near Tikrit, Iraq, and has lived for the past six years with PTSD.  Seven if you count the year he refused to admit that he had it because he never left the base or fired his weapon, and who was he to suffer when others had it so much worse?  Nearly 50 when he deployed, he was much older than most of his National Guard unit.  He had put in 17 years in various branches of the military, had a stable family, strong religious ties, a good education, and a satisfying career as a high-school English teacher.  He expected all that to insulate him, so it took a while to realize that the whole time he was in Iraq, he was numb.  In the end, he would be diagnosed with PTSD and given an 80% disability rating, which, among other benefits, entitles him to sessions with a Veterans Administration psychologist, whom he credits with saving his life.

Andy recalls a 1985 BBC series called “Soldiers” in which a Marine commander says, “It’s not that we can’t take a man who’s 45 years old and turn him into a good soldier. It’s that we can’t make him love it.”  Like many soldiers, Andy had assumed that his role would be to protect his country when it was threatened. Instead, he now considers himself part of “something evil.” So at a point when his therapy stalled and his therapist suggested that his spiritual pain was exacerbating his psychological pain, it suddenly clicked. The spiritual part he now calls his sacred wound. Others call it “moral injury.”

It’s a concept in progress, defined as the result of taking part in or witnessing something of consequence that you find wrong, something which violates your deeply held beliefs about yourself and your role in the world. For a moment, at least, you become what you never wanted to be. While the symptoms and causes may overlap with PTSD, moral injury arises from what you did or failed to do, rather than from what was done to you.  It’s a sickness of the heart more than the head. Or, possibly, moral injury is what comes first and, if left unattended, can congeal into PTSD.

What we now call PTSD goes way back.  In Odysseus in America, psychiatrist (and MacArthur “genius” grantee) Jonathan Shay has traced similar symptoms to Homer’s account of Odysseus’s homecoming from the Trojan War.  The idea that a soldier may continue to be haunted by his wartime life has had a name since at least the Civil War.  It was called “soldier’s heart” then, a lovely name for a terrible affliction.

In World War I, it went by the names “shell shock” and “war neurosis” and was so widespread that Britain devoted 19 hospitals solely to treating soldiers who suffered from it.  During WWII, it was called “battle fatigue,” “combat neurosis,” or “gross stress reaction,” and the problem was severe enough in the U.S. Army that, at one point, psychiatric discharges outpaced new recruits. The Vietnam War gave us the term “post-Vietnam syndrome,” which in time evolved into PTSD, and eventually the insight that, whatever its name, it is probably neurologically based.

PTSD’s status as an anxiety disorder — and as the only mental health condition officially defined as caused by a single, external event — was established in 1980, when it was enshrined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the bible of psychiatry. The diagnostic criteria have expanded since then and will probably be altered again in next year’s version of the DSM.  That troubles many therapists treating the ailment; some don’t think PTSD is a disease, others argue that the symptoms are just a natural response to being at war or that, in labeling it a disorder, political and cultural norms are being invoked to reinforce what is considered orderly.  As Katherine Boone, writing in the Wilson Quarterly, put it, “If you react normally to trauma, you have a disorder; if you act abnormally, you don’t.”

Most PTSD is short term, but perhaps one-third of cases become chronic, and those are the ones we keep hearing about, in part because it costs a lot to treat them.  For a variety of reasons, no one seems to have an exact number of recent combat veterans with PTSD.  The Veterans Administration estimates that between 11% and 20% of the 2.3 million troops who have cycled through Iraq and Afghanistan suffer from it, and the Congressional Budget Office calculates a cost of $8,300 per patient for the first year of treatment.  Do the math, and you could be talking about as much as $3.8 billion a year.  (What we’re not talking about nearly enough is the best way to prevent PTSD and other war-caused psychic distress, which is not to put soldiers in such untenable situations in the first place.)

Since the early days of diagnosis — when you were either sick with PTSD or you were fine — the medical response to it has gained in nuance and depth, which has brought beneficial funding for research and treatment.  In the public mind, though, PTSD still scoops up everything from risky behavior and aggression to substance abuse and suicide — kind of the way “Alzheimer’s” as a catch-all label stands in for forgetfulness over 50 — and that does a disservice to veterans who aren’t sick, but aren’t fine either.

“What you come into the war with will dictate how you come out of war,” Joshua Casteel testified about a soldier’s conscience at the Truth Commission on Conscience and War, which convened in New York in March 2010.  He had spent five months as an interrogator at Abu Ghraib shortly after the prisoner abuse scandal broke there.  He later left the Army as a conscientious objector after an impassioned conversation about faith and duty with a young Saudi jihadist, whom he was supposed to be questioning, led him to conclude that he could no longer do his job. Casting a soldier’s experience as unfathomable to anyone else was not only inaccurate, but also damaging, he said; he had never felt lonelier than when people were afraid to ask about his life during the war.

Our warriors today are all volunteers who signed up and are apparently supposed to put up with whatever comes their way.  As professionals, they’re supposed to be ready to fight, but as counterinsurgents they’re supposed to be tender-hearted and understanding — at least to kids, those village elders they’re fated to drink endless cross-cultural cups of tea with, and their buddies.  (Every veteran has a kid story, and mourning lost friends with tattoos, rituals, and drunken sorrow are among the few ways they’re allowed to grieve publicly.) They’re supposed to be anguished when they hear about the “bad apples” who gang-raped, then murdered and set fire to a 15-year-old girl near Mahmoudiya, Iraq, or the “kill team” that hunted Afghan civilians “for sport.”

Maybe it’s the confusion of these mixed signals that makes us treat our soldiers as if they’re tainted by some special, unwanted knowledge, something that should drive them over the edge with grief and guilt and remorse.  Maybe we think our soldiers are supposed to suffer.

The Right to Miss

A couple of decades ago, Dave Grossman, a professor of psychology and former Army Ranger, wrote an eye-opening, bone-chilling book called On Killing.  It begins with the premise that people have an inherent resistance to killing other people and goes on to examine how the military overcomes that inhibition.

On Killing examines the concerted effort of the military to increase firing rates among frontline riflemen.  Reportedly only about 15%-20% of them pulled the trigger during World War II.  Grossman suggests that many who did fire “exercised the soldier’s right to miss.”  Displeased, the U.S. Army set out to redesign its combat training to make firing your weapon a more reflexive action. The military (and most police forces) switched to realistic, human-shaped silhouettes, which pop up and fall down when hit, and later added video simulators for the most recent generation of soldiers raised on virtual reality.

This kind of Skinnerian conditioning — Grossman calls it “modern battleproofing” — upped the firing rate steadily to 55% in Korea, 90% in Vietnam, and somewhere near 100% in Iraq.  Soldiers are trained to shoot first and evaluate later, but as Grossman observes, “Killing comes with a price, and societies must learn that their soldiers will have to spend the rest of their lives living with what they have done.”

That price could be called moral injury.

The term may have come from Jonathan Shay, though he demurs.  Whatever its origin, it wasn’t until the end of 2009 that it began to resonate in therapeutic communities. That was when Brett Litz, the Associate Director of the National Center for PTSD in Boston, and several colleagues involved in a pilot study for the Marines published “Moral injury and moral repair in war veterans,” a paper aimed at other clinicians.  Their stated aim was not to create a new diagnostic category, nor to pathologize moral discomfort, but to encourage discussion and research into the lingering effects on soldiers of their moral transgressions in war.

The authors found that emotional distress was caused less by fear of personal harm than by the dissonance between what soldiers had done or seen and what they had previously held to be right.  This echoes Grossman, who concludes that the greatest cause of psychological injury to soldiers is the realization that there are people out there who really want to hurt you.

Moral injury seems to be widespread, but the concept is something of an orphan.  If it’s an injury, then it needs treatment, which puts it in the realm of medicine, but its overtones of sin and redemption also place it in the realm of the spiritual and so, religion.  Chaplains, however, are no better trained to deal with it than clinicians, since their essential job is to patch up soldiers, albeit spiritually, to fight another day.

Yet the idea that many soldiers suffer from a kind of heartsickness is gaining traction.  The military began to consider moral injury as a war wound and possible forerunner of PTSD when Litz presented his research at the Navy’s Combat Operational Stress Control conference in 2010.  The American Psychiatric Association is also thinking about adding guilt and shame to its diagnostic criteria for PTSD.  A small preliminary survey of chaplains, mental health clinicians, and researchers found unanimous support for including some version of moral injury in the description of the consequences of war, though they weren’t all enamored of the term.  As if to mark the start of a new era in considering the true costs of war, a new institution, the Soul Repair Center, has just been launched at Brite Divinity School in Fort Worth, Texas, with a $650,000 grant from the Lilly Foundation to conduct research and education about moral injury in combat veterans.

Of course, to have a moral injury, you have to have a moral code, and to have a moral code, you have to believe, on some level, that the world is a place where justice will ultimately prevail.  Faith in a rightly ordered world must be hard for anyone who has been through war; it’s particularly elusive for soldiers mired in a war that makes little sense to them, one they’ve come, actively or passively, to resent and oppose.

When your job requires you to pull sleeping families from their beds at midnight thousands of miles from your home, or to shoot at oncoming cars without knowing who’s driving them, or to refuse medical care to decrepit old men, you begin to question what doing your job means.  When the reasons keep shifting for what you’re supposed to be doing in a country where most of the population wants you to go home even more than you want to, it’s hard to maintain any sense of innocence.  When someone going about his daily life is regularly mistaken for someone who means to kill you — as has repetitively been the case in our occupations of both Iraq and Afghanistan — everyone becomes the enemy.  And when you try — and fail — to do the right thing in a chaotic and threatening situation, which nothing could have trained you for, the enemy can move inside you and stay there for a very long time.

In trying to heal from a moral injury, people struggle to restore a sense of themselves as decent human beings, but the stumbling block for many veterans of recent U.S. wars is that their judgment about the immorality of their actions may well be correct.  Obviously, suffering which can be avoided should be, but it’s not clear what’s gained by robbing soldiers of a moral compass, save a salve to civilian conscience.  And despite all the gauzy glory we swath soldiers in when we wave them off to battle, nations need their veterans to remember how horrible war is, if only to remind us not to launch them as heedlessly as the U.S. has done over these last years.

When you’ve done irreparable harm, feeling bad about your acts — haunted, sorrowful, distraught, diminished, unhinged by them — is human.  Taking responsibility for them, however, is a step toward maturity.  Maybe that’s the way the Army makes a man of you, after all.

Two final observations from veterans who went to war, then committed themselves to waging peace, apparently a much harder task: Dave Cline began his lifetime of antiwar work as a G.I. in the Vietnam War.  A few years into the Iraq War, when he was president of Veterans For Peace, he told me, “Returning soldiers always try to make it not a waste.”  The second observation comes from Drew Cameron in a preface to a book of poems by a fellow veteran, published by his Combat Paper Press: “To know war, to understand conflict, to respond to it is not an individual act, nor one of courage.  It is rather a very fair and necessary thing.”

Recognizing moral injury isn’t a panacea, but it opens up multiple possibilities.  It offers veterans a way to understand themselves, not as mad or bad, but as justifiably sad, and it allows the rest of us a way to avoid reducing their wartime experiences to a sickness or a smiley face.  Most important, moral repair is linked to moral restitution.  In an effort to waste neither their past nor their future, many veterans work to help heal their fellow veterans or the civilians in the countries they once occupied.  Others work for peace so the next generations of soldiers won’t have to know the heartache of moral injury.

Nan Levinson, a Boston-based journalist, reports on civil liberties, politics, and culture. Her next book, War Is Not a Game, is about the recent G.I. antiwar movement.Copyright 2012 Nan Levinson.  Photo credit:  Jared Rodriguez / Truthout.org (CC BY-NC-SA 2.0)

______

This article is copied without edit for educational purposes from The American Conservative.

.