in Service Members and Veterans Chaplain Kerry Haynes DMin MDiv BCCMH Mental Health Chaplain San Antonio VA Objectives Describe moral injury Differentiate moral i njury from PTSD ID: 563940
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Slide1
PTSD and Moral Injury in Service Members and Veterans
Chaplain Kerry Haynes
D.Min
., M.Div., BCC/MH
Mental Health Chaplain
San Antonio VASlide2
ObjectivesDescribe moral injury
Differentiate moral
i
njury from PTSD
Review mental health (MH) interventions for moral injury
Address possible MH and chaplain approaches to moral injurySlide3
Moral injury Definition #1 (Shay, 1994)A betrayal of what’s “right”
B
y
someone
who holds legitimate authorityIn a high stakes situation But what if the “someone” is YOU?Slide4
Moral injury Definition #2 (Litz et al., 2009)
Harm caused by “perpetrating, failing to prevent, witnessing, or learning about actions that violate deeply held moral beliefs and expectations “
Litz
et
al.,
2009. “Moral injury and moral repair in war veterans: A preliminary model and intervention strategy.” Clinical Psychology Review, 29, 695-706.Slide5
More from Litz et al.“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
.”
Litz
et al, 2009. “Moral
injury and moral repair in war veterans: A preliminary model and intervention strategy
.”
Clinical Psychology Review, 29,
695-706
.Slide6
In the eye of the beholderMoral transgression is subjectiveBased on Veteran’s own moral standards, expectations, and interpretationSlide7
Model of Moral Injury
Sheila Frankfurt, Ph.D
., VISN
17 Center of Excellence for Research on Returning War
Veterans, “
Impact of Moral Injury on Post-deployment Mental HealthSlide8
Some Causes 0f Moral InjuryActs of betrayal by peers,
leaders, or self
Disproportionate
violence inflicted on
others
Death or harm to civiliansViolence within military ranksConcealed acts of cowardice, failure to do dutyExposure to body parts
Inability
to prevent death or suffering
Resulting
in ethical dilemmas or moral conflicts Slide9
PTSDAnxiety & fear
Diagnosis in DSM-5
Does not require moral injury
Guilt & shame
Dimensional problem
Does not require PTSD
moral InjurySlide10
Avoidance
Re-experiencing
Grief/Loss
Hypervigilance
Guilt/Shame
Focus on fear-based responses
Treatment based on exposure and re-evaluation of cognitions
Higher sense of alienation and purposelessness
Treatment addresses moral conflict and self-condemnation
PTSD
Moral Injury
SYMPTOMS OVERLAP
Jaimie Lusk and Rebecca Morris, “Religion/Spirituality
and
Suicidality.” Presentation given at Portland, OR VA, June 30, 2016.Slide11
Fear Conditioning, loss, and moral injurya
William P. Nash, “Common Goals for Preventing and Repairing Moral Injury,”
DCoE
Chaplains Working Group Teleconference, 4 March 2015.Slide12
The Case of THE USS Morton (DD-948)David A. Thompson, “Moral Injury: An Often Untreated Veteran Injury,” in The Military Chaplain
, Fall 2014; pp. 6-8.Slide13
The Case of THE USS DUBUQUE (LPD-8)David A. Thompson, “Moral Injury: An Often Untreated Veteran Injury,” in The Military Chaplain
, Fall 2014; pp. 6-8.Slide14
TWO Routes to Trauma
Terror of one’s own
vulnerability (PTSD?)
The
world is not
benevolent nor meaningful. I am not protected by virtue of who I am or what I do.Horror of one’s own immorality (PTSD and/or moral injury
?)
I
am not
worthy. I
am not acceptable to the human
community.
Ronnie
Janoff-Bulman,
“Shattered
Assumptions:
Toward
an Understanding of
Trauma,”
Presentation
to VA
Chaplains, April 9, 2013Slide15
Modern WarfareBetter medical care prolonging life
More lethal weapon systems
Ambiguous enemy (indigenous insurgents)
Atrocities involving civiliansSlide16
Distinction between Moralities
Interpersonal
Morality in the context of one-to-one interactions
Basic rule:
“do no harm
”
Group
Morality in the context of group memberships
Basic rule: “
protect the group
”
Ronnie
Janoff
-Bulman, “Shattered Assumptions: Toward an Understanding of Trauma,”
Presentation to VA Chaplains, April 9, 2013Slide17
When Veterans Come HomeS
hift
to
completely changed context (default to interpersonal morality)
Removed from war context Not with buddies/unit With others who use interpersonal standard and don’t understand war experiences Veteran no longer understands: horror of his/her own immorality
Ronnie
Janoff
-Bulman, “Shattered Assumptions: Toward an Understanding of Trauma,” Presentation to VA Chaplains, April 9, 2013Slide18
Coping: Rebuilding one’s world
Fundamental
assumptions that can incorporate
experiences
, yet allow for adaptive
functioningRe-establishing relative sense of invulnerabilityRe-establishing sense of self worth, morality
Ronnie
Janoff
-Bulman, “Shattered Assumptions: Toward an Understanding of Trauma,” Presentation to VA Chaplains, April 9, 2013Slide19
Social Support
Crucial
for coping
Protective factor
Provides evidence that:
World is benevolent, meaningfulSurvivor is deemed worthy
Counseling – provides understanding confidant
Groups = mini-community
Ronnie
Janoff
-Bulman, “Shattered Assumptions: Toward an Understanding of Trauma,”
Presentation to VA Chaplains, April 9, 2013Slide20
Implications for CARE
Sensitivity to the
two types of trauma
Terror of one’s own vulnerability:We can minimize likelihood of negative events
Horror of one’s own immorality
:
Keep in context: What seems terrible now was done in another setting (war) that involved
different moral standards
(protecting the group as paramount)
Consider self-forgiveness/making amends
Ronnie
Janoff
-Bulman, “Shattered Assumptions: Toward an Understanding of Trauma,”
Presentation to VA Chaplains, April 9, 2013Slide21
Multi-dimensional Moral repair
William P. Nash, “Common Goals for Preventing and Repairing Moral Injury,”
DCoE
Chaplains Working Group Teleconference, 4 March 2015.Slide22
Post-Traumatic Growth (PTG)
The
world isn’t always
meaningful, but one can
create meaning (value) through
commitments and newfound appreciation of lifeRecognize possibility
for good and bad in all of us
– can
choose the good
Greater
compassion for
others – Veterans
helping
Veterans
Agonizing
experiences
bring the
possibility for profound growth Slide23
Evidence-Based TreatmentsProlonged Exposure Therapy (PE)
Repeated exposure of trauma-related thoughts, feelings and situations
Education
Breathing (self-soothing)
Real-world exposure practice
Talking through the traumaNot so effective with shame (reliving)Slide24
Evidence-Based TreatmentsCognitive-Processing Therapy (CPT)
Tackles assimilated/distorted beliefs related to the trauma and over-generalized beliefs about oneself and the world
C
lients identify “stuck points” (conflicting beliefs, leaps of logic, or unsupported assumptions)
May include work on guilt (appropriate vs. inappropriate) and acts of perpetration
Providers may not include helpful spiritual/religious practices important to patientSlide25
Moral Injury as Catalyst for Manufactured EmotionsAssociated with guilt, shame, and anger at self and others Guilt – what I did
Shame
– who I am
Work
to reduce/eliminate inappropriate manufactured emotions
Work to right-size appropriately-placed guiltSlide26
Treatments UNDER TRIALImpact of Killing in War (IOK)
Six-session cognitive-behavioral group
Education on bio-psycho-social aspects of killing in war that may cause inner conflict
Identification of meaning elements and cognitive attributions
Self-forgiveness (cognitive therapy and/or spiritual/religious practices)
Making amends tailored to the individualSlide27
Treatments UNDER TRIALAdaptive Disclosure (AD)
Eight-session group
Addresses moral injury and traumatic loss
Brief exposure
to address core features and meaning of combat trauma events
If focal trauma is loss-based, imaginary real-time dialogue with the lost personFor moral injury, guided real-time dialogue with a forgiving and compassionate moral authoritySlide28
Why involve the chaplain?Specialist in guilt, shame, forgiveness, restoration, community, and ritualMoral/ethical authority
Representative of the Divine
Less stigma than seeing a MH provider?Slide29
Indispensable Qualities for providers in moral injury workNon-judgmentalNon-anxious
Compassionate
Patient with the struggle
Transparent (appropriately)
Engaging where they areSlide30
GROUP VS. individualindividual
Less threatening initially (with warm, accepting chaplain)
Tailored to unique needs
More time intensive
Less community building
groupMore threatening initially (unless safety in numbers)
Less tailored to unique needs
Less time intensive
More community buildingSlide31
GROUP optionsopen
Easier to try out
Easier for referrals
Source for closed group recruitment
closed
Higher commitment levelBuilds trust quickerBuilds stronger communityMore appropriate for moral injury?Slide32
Options for facilitationMental health (MH) provider aloneChaplain alone
Chaplain and MH provider co-leadingSlide33
va MORAL INJURY Groups co-led by MH Provider and ChaplainMemphis
Nashville
Portland
Loma Linda
Providence
Mountain HomePhiladelphiaIndianapolisSlide34
va MORAL INJURY Groups LED by Chaplain ALONEHampton
San Diego
Charleston
San AntonioSlide35
San Antonio va initiativesOpen ongoing
PTSD C
h.-led group
Closed Ch.-led moral injury groups (6-12 sessions)
Testing Spiritually-oriented Cognitive Processing Therapy (SOCPT)
Research study with Harold Koenig, M.D.Slide36
Spiritually-Oriented Cognitive processing therapy (SOCPT)Targets erroneous interpretations of trauma
F
ocuses
on cognitive restructuring using clients’ religious
resources
to challenge maladaptive thinking patterns Targets moral injuryTargets religious/spiritual struggles and loss of faith Pearce MP, Haynes K, Koenig HG (2016). “Spiritually Oriented Cognitive Processing Therapy.” Durham, NC: Duke University Center for Spirituality, Theology and Health. Appendix [planned] to
Resick
et al. (2014).
“Cognitive
processing therapy: Veteran/military version: Therapist’s manual
.”
Washington, DC: Veterans Administration.Slide37
Spiritually-Oriented Cognitive processing therapySeeks to reverse negative emotional responses (shame, guilt, anger, humiliation) by emphasizing healthier concepts of …
Mercy
Grace
Confession
Repentance
Penance
Forgiveness
Spiritual surrender
Prayer/contemplation
Divine justice
Hope
Divine
affirmationsSlide38
Spiritually-Oriented Cognitive processing therapyIncludes powerful rituals
Encourages engagement in Veteran’s chosen religious community
Addresses
moral injury
from within the person’s own
spiritual/religious systemFuture writings: Chaplain intervention for moral injuryReligious-specific SOCPT manualsSlide39
Research studyMulti-site study for combat Veterans with PTSD symptomsCoordinated by Harold Koenig, M.D.,
Duke U.
Measures Veterans’ …
PTSD symptoms
Moral injury symptoms
Openness to spiritually-oriented therapy Future study: effectiveness of SOCPT vs. CPTSlide40
Moral Injury Programs and a Film Premiere
Sunday
, November 20,
2016, 1-7 pm
Grand Hyatt Hotel, Texas Rooms E & A
Free and Open to the PublicDress: Business CasualHosted by the Soul Repair Center at Brite Divinity School, the Moral Injury in Religion, Society, and Culture Group of the American Academy of Religion, and Odyssey NetworksSlide41
BRANDON COURTNEYPoetry Reading, November 1, 6:00 pmSeddon Recital
Hall, University of Incarnate Word
Q&A and Book Signing
Award-winning poet and veteran of the
Navy
and Operation Enduring FreedomFor additional information, contact:Dr. Joshua Robbins (joshua.robbins@uiwtx.edu)Dr. Zenon Culverhouse (fculverh@uiwtx.edu)Slide42
Questions/comments?
Kerry Haynes, D.Min., BCC/MH
Mental Health Chaplain
San Antonio VA
210-617-5300, ext. 13317
Kerry.Haynes@va.govSlide43
bibliographyBrock, Rita and Gabriella Lettini.
Soul Repair: Recovering from Moral Injury After War
. Boston: Beacon Press, 2012.
Currier
, Joseph, Jason Holland, and Jesse Malott. “Moral Injury, Meaning Making, and Mental Health in Returning Veterans.”
Journal of Clinical Psychology 71, no. 3 (March 2015): 229–240.Currier, Joseph, Jason Holland, Kent Drescher, and David Foy. “Initial Psychometric Evaluation of the Moral Injury Questionnaire-Military Version.” Clinical Psychology and Psychotherapy 22, no. 1 (2015): 54-63.Drescher, Kent, David Foy, Caroline Kelly, Anna Leshner, Kerrie Schutz, and Brett Litz. “An Exploration of the Viability and Usefulness of the Construct of Moral Injury in War Veterans.”
Traumatology
17, no. 1 (March 2011): 8-13. Slide44
bibliographyGray, Matt J, Yonit
Schorr
, William Nash, Leslie
Lebowitz
, Amy
Amidon, Amy Lansing, Melissa Maglione, Ariel Lang, and Brett Litz, “Adaptive Disclosure: An Open Trial of a Novel Exposure-based Intervention for Service Members with Combat-related Psychological Stress Injuries,” Behavior Therapy 43, no. 2 (June 2012), 407-415.Handzo, George. “Spiritual Care and Moral Injury in Service Members.” Caring Connections 10, no. 1 (Winter 2013): 6-8. Kidwell, Julia and Nathaniel Wade, “Christian-Accommodative Group Interventions to Promote Forgiveness for Transgressions,” in Evidence-based Practices for Christian Counseling and Psychotherapy
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.Slide45
bibliographyKim, Jichan and Robert Enright. “A Theological and Psychological Defense of Self-Forgiveness: Implications for Counseling.”
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29, no. 8 (December 2009): 695-706.
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, Shira and Brett Litz. “Moral Injury in the Context of War.” Last modified January 20, 2015, accessed February 18, 2015. http://www.ptsd.va.gov/ professional/co-occurring/ moral_injury_at_war.asp.McConnell, John and David Dixon. “Perceived Forgiveness from God and Self-forgiveness.” Journal Of Psychology and Christianity 31, no. 1 (2012): 31-39.Slide47
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