1. Post Traumatic Stress Injury (PTSI) and Moral Injury in Combat Vets Chaplain Robert Thomas, D Min BCC Chief, Pastoral Care Service VA Sierra Nevada Health Care System Reno, NV 89502 1

2. Definition of Terms Post Traumatic Stress Disorder (PTSD) - Classified under “Anxiety Disorders” in the Diagnostic Standards Manual (DSM)-IV - Moved under “Trauma and Stressor-Related Disorders” in DSM-5 “Direct exposure, witnessing, learning about, or experiencing repeated or extreme adverse details about actual or threatened death, serious injury, or sexual violence resulting in intrusion symptoms, avoidance characteristics, negative alterations in cognitions, mood, arousal and reactivity which causes clinically significant impairment in social, occupational or other important areas of functioning.” (DSM-5 p. 271-2) - Object to “disorder,” prefer “injury”– Post Traumatic Stress Injury (PTSI) 2

3. Injuries Relating to Combat Post Traumatic Stress Injury (PTSI) The person experienced, witnessed, or was confronted with event(s) that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; response involved intense fear, helplessness or horror. Symptoms: *anxiety *hypervigilance *increased arousal *exaggerated startle response *recurring dreams and nightmares *irritability *psychological distress *anger *avoidance behaviors *difficulty concentrating *avoidance behaviors *difficulty concentrating *psychic numbing *foreshortened future *isolation and estrangement*sleep disorders *anhedonia Wound is psychological, but with very physical manifestations 3

4. Moral Injury Perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations; feelings of betrayal. *Feeling unforgiven and unforgivable *Always on the margins of society (i.e., “don’t fit in” - withdrawal) *Always on the margins of society (i.e., “don’t fit in” - withdrawal) *Estranged from God, church or faith community, friends *Estranged from God, church or faith community, friends *Feeling unheroic (“if you only knew what I did…”) *Feeling unheroic (“if you only knew what I did…”) *Unreconciled spirit *Unreconciled spirit *Feeling in perpetual state of moral ambiguity *Feeling in perpetual state of moral ambiguity *Seething anger and frustration *Seething anger and frustration *Numbing behaviors (drugs, alcohol) *Numbing behaviors (drugs, alcohol) Wound is to the Soul and Spirit 4

5. What is Missed by Current Conceptions of PTSD? Litz, et. al., 2009, Moral Injury and Moral Repair Directly experiences the traumatic event(s). (A1 Criterion) Individual’s role at time of event Witnessing, in person, the event(s) as it occurred to others. (A2 Criterion) Re-experiencing? (B Criterion) Persistent avoidance of stimuli? (C Criterion) Negative cognitions and mood, and arousal? (D and E Criterion) What necessity is lost? In War Veterans: A Preliminary Model PTSDMoral Injury Actual or threatened death, serious injury or sexual violation Acts that violate deeply held moral values Victim or WitnessPerpetrator, victim or witness Fear, horror, helplessness (DSM- IV) DSM-5 includes guilt, horror, shame Guilt, shame, anger YES NO SafetyTrust 5 DSM-5, p. 271-272

6. The Honorable Work of the Warrior  Psalm 18:34 “He trains my hands for battle; my arms can bend a bow of bronze.” Rom 13:4  Bhagavad-gita 2.31, “And even considering your personal dharma as well, it is not right for you to hesitate. There is nothing better for a warrior, than a fight based on dharma.”  R. Calloway, “A true warrior does not train tirelessly to fight or to kill. A true warrior trains endlessly that he/she may return home alive.”  Tom Clancy, The sum of all Fears, “The noblest of ideas have always been protected by warriors.” 6

7. Even Honorable Warriors May Experience PTSD David: The valley of death-shadow (Psalm 23) Sons of Korah: Rejection by the people following battle in a foreign land (Psalm 44:13-16) Warriors of Israel: Survived the battle (Psalm 107:2) but suffered homelessness, poverty and rejection (vv. 4-5; 10-13) People of Galilee: Living in death-shadow (oppression of foreign power), the light of the Christmas Promise will shine and bring freedom (Isaiah 9:2-7) 7

8. Theodicy : Arguments in defense of God’s goodness despite the existence of evil. Problem (Epicurus): 1. If God would remove all evil from the world but cannot = impotent. 2. If God can remove all evil from the world but will not = malevolent. 3. If God is able and willing to remove all evil, why is there evil? “God went AWOL in Vietnam!” “That’s when I decided God was not there.” Wound is to the belief system (loss or corruption of the assumptive world) Philosophical/Theological Issue (Theodicy) 8

9. Counterinsurgency and the Moral Compass, Litz, 2009, Moral Injury Despite strong battlefield ethics training and the rules of engagement, unconventional features of war may make it more difficult for service members to maintain a moral compass.  Over half of the soldiers felt that non-combatants should not be treated with dignity and respect  31% indicated they had insulted or cursed at civilians  20% of soldiers reported responsibility for the death of a non- combatant  17% of soldiers surveyed believed that non-combatants should be treated as insurgents  11% reported damaging property unnecessarily  5% indicated mistreating civilians 9 Litz, Brett; et. Al.; Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy, in Clinical Psychology Review, 2009.07.003

10. 10 Spiritual Consequence of War Cipolla, Benedicta, Healing the Wounds of War, Religion & Ethics NewsWeekly, 2007.11.30.

11. Spiritual Consequence of War 11 Cipolla, Benedicta, Healing the Wounds of War, Religion & Ethics NewsWeekly, 2007.11.30.

12. Then There is the Chris Kyle Experience American Sniper “I will stand before my Maker and give an account for every shot I took.” - Kyle felt justified - Morally and ethically approved - Film is a study on the impact of PTSD and Moral Injury in spite of moral justification 12

13. Deployment Length and Multiple Deployments Can create cumulative anger and frustration about losses, sacrifices, and adversities may impact ethical decision-making. For example: deployment length has been found to be associated with an increase in unethical behaviors on the Battlefield. 13

14. Guilt Guilt is a painful and motivating cognitive emotional and spiritual experience tied to specific acts of transgression of a personal or shared moral code or expectation. Guilt is not always a bad thing 14

15. Shame Shame involves global evaluations of the self along with behavioral tendencies to avoid and withdraw. It results in more toxic interpersonal difficulties, such as anger and decreased empathy for others. These experiences can lead to devastating life changes. Research has shown that shame is more damaging to emotional and mental health than guilt. Consequently, shame may be a more integral part of moral injury. 15

16. Betrayal Many soldiers experience moral injury as a result of feeling betrayed by a trusted authority or structure Tactical command structure (CO, LT, platoon sergeant) Tactical command structure (CO, LT, platoon sergeant) Strategic command structure (Generals, Pentagon, Joint Chiefs) Strategic command structure (Generals, Pentagon, Joint Chiefs) Government (Congress, the President, SecDef) Government (Congress, the President, SecDef) Religious communities that marginalize the soldier/veteran Religious communities that marginalize the soldier/veteran A nation that turned its back on all of them A nation that turned its back on all of them 16

17. Guilt is what I feel for what I’ve done External to self, because it focuses on self behavior Shame is what I feel for who I am Internal – is appraisal of the self Betrayal produces a sense of victimization External to self, caused by others My pain is someone else’s fault 17

18. Implications for Nursing Mental Health Assessment  Nurses need to “stop being afraid” of asking about religious/spiritual issues  Understand the importance of religious/ spirituality in patient’s lives, “do not gloss over the issue”  Sequencing of value/belief question(s) as it relates to patient’s strength  Ask what brings meaning/purpose to life? 18

19. How Does a Soldier Return?  Homer’s The Odyssey – returning is difficult and a long struggle  Mosaic Law: Numbers 31:19-20  Native American cleansing ceremony  American way: “Suck it up, buttercup…” 19

20. There is a Way Back… 1. Connection – begins with strong therapeutic relationship 2. Plan – accepting group, successive steps forward - The Combat Trauma Healing Manual 3. Emotional Reliving – “Leaning into the wind” 4. Introspection – at the deepest level of self, who am I? 5. Conversations with God/Higher Power - Disclose the transgression, if any (confession) - Articulate how one feels about self (guilt, shame, victimization) - Acknowledge what should be the outcome (justice, judgment, personal responsibility) personal responsibility) - Ask for forgiveness based on God’s mercy and grace (repentance) - Grant forgiveness to those who wronged you (letting go victimhood) - Receive reassurance based on God’s promises (grace, forgiveness) - Plan for reparations where able (fruits of repentance) 20

21. There is a Way Back… Continued 6. Healing ritual 7. Cultivate goodness – art, beauty, peace, harmony 8. Re-connect – family, friends, church community 9. Plan for the long haul – rarely a “quick fix” 21

22. Case Studies 22

23. Patient in ICU “ Felt God had abandoned him” Patient in Inpatient Mental Health “Angry with God” Patient in ICU “God did not save his teenage daughter who had cancer, so patient feels forgotten by God” RESPONSES 23

24. Final Comment “My sense is that this is a fundamentally religious issue. It’s possible to package it as a mental health issue, but I think we lose out. Even people who have had good secular treatments for their trauma still feel a need for the religious dimension of it. I don’t think as a society we are offering it.” Jonathan Shay, author of Achilles in Vietnam (1995) 24

25. References Adsit, Chris. The Combat Trauma Healing Manual – Christ Centered Solutions for Combat Trauma. Newport News, VA: Military Ministry Press, 2008. Cipolla, Benedicta, Healing the Wounds of War, Religion & Ethics NewsWeekly, 2007.11.30. Drescher, Kent; Foy, David; Kelly, Caroline; Leshner, Anna; Schultz, Kerrie; Litz, Brett. An Exploration of the Viability and Usefulness of the Construct of Moral Injury in War Veterans, in Traumatology. Published online 10 March 2011. Hoge, Charles W. Once a Warrior Always a Warrior – Navigating the Transition from Combat to Home – Including Combat Stress, PTSD, and mTBI. Guilfore, Conn: Globe Pequot Press, c. 2010. Litz, Brett; et. Al.; Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy, in Clinical Psychology Review, 2009.07.003. Maguen, Shira and Litz, Brett. Moral Injury in Veterans of War, in PTSD Research Quarterly, Vol 23, No. 1, c. 2012. Marlantes, Karl. What It Is Like to Go to War. New York: Atlantic Monthly Press, c. 2011. Shay, Jonathan. Achilles in Vietnam – Combat Trauma and the Undoing of Character. New York: Simon & Schuster, c. 1994. Tick, Edward. War and the Soul – Healing Our Nation’s Veterans from Posttraumatic Stress Disorder. Quest Books, 2005. 25