March 15, 2020
VA, DoD recommended PTSD therapies don’t help many military patients, review finds
The Suicide Epidemic
Why are veterans and first responders continuing to suicide at an unprecedented rate? At the Center for Post Traumatic Growth (CPTG) we believe moral injury may be a root cause. Moral injury occurs when people of service are put into situations in which they are unable to prevent harm to others or believe they have perpetrated harm on others. Brett Litz and his colleagues (2009) operationally defined the term Moral Injury as the, “The lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” The term was first coined by Johnathan Shay (1994) when describing the “undoing of character” he observed in Vietnam veterans.
The field of mental health has only begun to recognize the role of moral injury in the suffering of veterans and others. Yet, despite all of the discussion and recent writings regarding the concept, very few interventions have been developed to address moral injury directly. The current evidence-based treatments have been developed to address the symptoms associated with Post Traumatic Stress Disorder (PTSD), but they fall short when addressing the core issues of moral injury including unresolved loss, guilt and shame. Moral injury often co-occurs with Post Traumatic Stress (PTS), but one condition may exist without the other. We look at them as the “same species, but a different animal”. For us to assist those with moral injury to heal, we must know what we are treating and use the appropriate interventions or we risk making moral injury worse.
Rita Brock (2012), Edward Tick (2005), and Litz, Lebowitz, Gray and Nash (2016) are among the few who have implemented specific interventions for moral injury to date.
At the Center for Post Traumatic Growth, it is our contention that moral injury is not a disorder. Moral injury develops when highly competent and principled individuals (people of service) are repeatedly exposed to events which violate their deeply held moral values and expectations. It is the most competent, compassionate, and principled people that are the most vulnerable to these kinds of wounds, as these very qualities that help them excel are also what makes them more vulnerable to being morally injured. One of our veterans expressed his internal experience of moral injury this way, ”I feel like I have forfeited my membership card in humanity.” Moral injury creates a sense of alienation from others and the rest of humanity because they believe they have violated the basic convents of human conduct regarding how we treat one another. In short, moral injury stems from broken relationships between people; the severing of human connection through traumatic loss or perceived transgression against others.
Imagine: You are the driver of the lead Humvee in a convoy on a mission in Iraq. The insurgents send a child into the road in an attempt to stop the convoy. What do you do?
You run the child over because to do otherwise you put your brothers and sister in danger and compromise the mission. As your vehicle strikes the child you feel the vehicle bounce over the child’s body. In the rear-view mirror you see bloody carnage left behind.
When you return to base you are ordered to take the Humvee to the transportation section and clean the child’s body parts from the front of the vehicle.
When you return home from your second tour in Iraq and your little girl has her 4th birthday party, she and the other children in attendance are the approximate age of the child you ran over in Iraq. The night after the party you begin to have flashbacks and you often feel the physical bump of the child’s body under your truck. You have recurrent dreams of running over your own little girl. The Iraqi child begins to visit you in your dreams and asks you “Why did you kill me?”
You can’t talk to your spouse, family or friends because then they will know you are a baby killing monster and in your heart of hearts you know you would do it again.
Things are unraveling. Your spouse says you need to get help. So, reluctantly you go to the VA and ask for help. They give you pills for sleep and nightmares, and put you on an antidepressant that makes you groggy much of the time. They recommend a course of Cognitive Processing Therapy (Resick, Monson, Chard, 2016) , what they call their “gold standard” for treatment. You attend 12 sessions, where initially you are asked to write out the details of the event. The therapist finds your “stuck points” and then you are asked fill out worksheets disputing your guilt about killing a child. These are called “manufactured emotions” based on faulty thinking. Your therapist tells you “it was not your fault. You had no choice. When you can change these faulty thinking patterns to logically understand you were not at fault, your guilt will go away”.
It doesn’t work, so the VA offers you a course of Prolonged Exposure (PE) therapy (Foa & Rothbaum, 1998). This treatment was developed to mitigate, fear-based, body responses such as anxiety and hyperarousal when a life-threatening event is recalled. You decide to give it a try. You were involved in many “life threatening events”, but those don’t bother you as much as the little girl. You meet with the VA psychologist and you spend each session recounting in detail your “life threatening event.” Your therapist tapes your account of the event and tells you to listen to the tape between sessions and to note your “Subjective Units of Distress Rating”, called a SUDS, on a scale from 1 to 10. This will measure your gradual desensitization to this event. After every session you are exhausted. You do notice the event is easier to discuss, but you are still dreaming about the little girl asking, “Why did you kill me?” You still feel like a monster. The VA says that you have been through the best treatments they have to offer. They tell you to “keep taking your meds.”
So you continue to withdraw, you don’t interact with your daughter as much, you don’t hold her or read to her anymore, because she triggers flashbacks and deep feelings of guilt and shame. You start to tell yourself you don’t deserve her and you’re a shitty parent. “Maybe she would be better off without me.” You start drinking heavily to numb yourself, to sleep, and block the nightmares. You lose your temper over seeming little things and you know your daughter is becoming afraid of you. You avoid going to your daughter’s school functions and soccer games because you can’t stand crowds. You try going back to your church and even talk to the pastor about what you did. She tells you that it was not your fault and that you have been forgiven by God. You don’t feel forgiven.
Then you find out your daughter has leukemia. You believe that this must be punishment for killing that child in Iraq. One night you have been drinking and you put your gun to your head, you think about pulling the trigger to end your pain, despite knowing what it would do to your family…you just want the torment to stop…
At the Center for Post Traumatic Growth we have heard many stories just like this one in our treatment of thousands of veterans since 2001 (Keenan, Lumley & Schneider 2014). This is why we must start treating moral injury if the suicides are to stop.
At the Center for Post Traumatic Growth we have developed a three-phase group treatment program for treating those with moral injury. If unresolved loss and moral injury stem from the severed relationships between people, then we believe the healing of these injuries must be in relationship with others. We believe two conditions need to be accomplished for healing to occur. First, one must communicate directly with those lost or harmed. This is accomplished in a 9-month trauma focus group where the veterans write letters directly to the others who were lost or they believe they harmed. Then the letter is read aloud to the group, a community of worthy others, who have walked the same path.
Letter writing allows the direct communication between the individual and those lost or harmed. The letter transcends time, space and dimension. The group provides feedback to the individual about the letter helping the individual to process the event more deeply and to create a new relationship to the trauma narrative and to those lost or those harmed.
How do we know the letters work?
The transformation of individuals lost or harmed nearly always occurs through either a dream or a transformation event. This phenomenon was described by Shay (1994), who stated that providing a narrative can transform distressing re-experiencing symptoms into welcomed memories, allowing the veteran to gain control of the traumatic recollections; we believe, a reflection of the repair to the interpersonal breach. One veteran we worked with described a transformation dream of his best friend. This veteran had often discussed his buddy, Sam, in session and stated they had become very close because they were both avid fishermen and frequently talked about fishing to pass the time. The veteran witnessed Sam burn to death after a rocket-propelled grenade hit the gun truck he was manning and exploded in flames. This veteran had labeled himself a coward because he thought he had not done enough to save Sam. After reading the letter in which he expressed his feelings for Sam and asked for forgiveness for not saving him, the veteran reported a dream in which he received a card with his name on the front and a smiling picture of Sam on the inside. Sam had written about how much he admired and missed the veteran, and that he was well and happy because he was living on a houseboat surrounded by fish. After describing his dream, the veteran looked into his therapist’s eyes and said, “I know where that card came from; it came from Heaven.” Notably, this transformation occurred within the veteran’s own spiritual framework and clearly reflects the shifting perception of his feelings of guilt, as well as the reconnection he established with his fond memory of Sam.
As we understand more about moral injury, applications for such an approach, with other populations exposed to trauma, begin to come into focus. We believe that our conceptualization of traumatic loss and moral injury may prove effective for other populations of traumatized individuals given the fact that trauma occurs between people in nearly all contexts. Another core part of our work is found within facilitating and supporting the grief process, which very often goes unnoticed and untouched, even by mental health practitioners. Understanding that any human trauma involving loss and disconnection from self and others deserves patience, depth, and the communalization of trauma for healing. Conversely, our contemporary mental health health system "pathologizes" guilt and the grief; and in damaging ways can dismiss and ultimately invalidate the veterans' internal experiences. Our program seeks to combat guilt and shame through an affective, psychodynamic, and existential medium, which gets at the root of PTSD and moral injury. Cognitive Behavioral Therapy approaches have little to no impact on moral injury in this way. We also currently provide this treatment with success to survivors of Military Sexual Trauma (MST). We have also used the approach successfully with Gold Star families. We are currently working to train others to offer our approach to first responders with moral injury (police, firefighters, EMT’s). Other potential populations include: survivors of terror attacks or mass shootings, victims of natural disasters, victims of violent/hate crimes, victims of political violence, cases of traumatic bereavement through accident or illness, accidents: Motor vehicle accidents, industrial accidents, and gang related violence.
If we can begin to offer interventions that address the core aspects of trauma, unresolved loss, guilt and shame (i.e. moral injury). We believe we can reduce the number of those individuals who lose hope and turn to suicide to alleviate their anguish.
Brock, R., Lettini, G., (2012). Soul Repair: Recovering from Moral Injury After War. Boston, MA: Beacon Press.
Foa, E. B., & Rothbaum, B. O. (1998). Treating the trauma of rape: Cognitive-behavioral therapy for PTSD. New York, NY: Guilford Press.
Keenan, M. J., Lumley, V. A., & Schneider, R. B. (2014, March 17). A Group Therapy Approach to Treating Combat Posttraumatic Stress Disorder: Interpersonal Reconnection Through Letter Writing. Psychotherapy.
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.
Litz, B., Lebowitz, L., Gray M., & Nash, W., (2016). Adaptive Disclosure: A new Treatment for Military Trauma, Loss and Moral Injury. New York, NY: Guilford Press
Resick, P. A., Monson, C. M., & Chard, K. M. (2008). Cognitive processing therapy: Veteran/military version. Washington, DC: Department of Veterans’ Affairs.
Shay, J. (1994). Achilles in Vietnam: Combat trauma and the undoing of character. New York, NY: Scribner.
Tick, E. (2005). War and the Soul. Wheaton, IL: Quest Books.