Partnering for Moral Injury Interventions Across the Wide

Partnering for Moral Injury Interventions Across the Wide Chaplaincy Landscape Jan Mc. Cormack DMin; APC/BCC; ACPE/Associate Supervisor jan. mccormack@denverseminary. edu APC Spring Symposium © 2017 62

Moral Injury: An ancient wound with a new construct Throughout history, warriors have been confronted with moral & ethical challenges. and modern unconventional & guerrilla wars amplify these challenges…. [T]he lasting impact of morally injurious experience in war remains chiefly unaddressed. B. T. Litz, N. Stein, E. Delaney, L. Lebowittz, W. P. Nash, C. Silva, and S. Maguen “The Soldier, above all other people, prays for peace, for (s)he must suffer and bear the deepest wounds and scars of war. ” General Douglas Mac. Arthur

A Moral Injury (Moral Wound) is… • the injury/wound to the soul experienced as a result of a traumatic event. • a disruption in an individual’s confidence & expectations about his/her own moral behavior or others’ capacity to behave in a just and ethical manner. B. T. Litz, N. Stein, E. Delaney, L. Lebowittz, W. P. Nash, C. Silva, & S. Maguen • the injury/wound in the soul that results when two deeply held ethics/beliefs collide & must result in choosing one ethic/belief over the other. Mc. Cormack

Aspects of Moral Injury Formation • Participation in events that challenge core beliefs or have no clear moral choices, including violating moral codes of training, esp. in a closed system • Use of personal agency that violates core moral beliefs • Reflection on memories and extreme conditions of extremity • Agony of inner judgment against oneself • Feelings of grief, anger, despair, guilt, shame, remorse, betrayal, contrition, depression, isolation, and loss of will to live • Collapse of moral identity and the meaning system that supports it Brock & Keizer webinar

Moral Injury/Wounds Can Happen to Anyone

Results from a Traumatic Event Such as… 1. Death (of a Child esp. ) 2. Combat/War 3. Terrorism 4. Mass Shootings 5. Rape 6. Natural Disasters 7. Sexual Trafficking 8. Death of a Colleague 9. Serious Health diagnosis/death 10. False public accusations 11. Handling human remains

Unjust, Unethical, Immoral Behavior of Others 1. Shot/Killed (an unarmed person, a fellow athlete, 2. 3. 4. 5. friendly fire, a patient w/wrong diagnosis/med, made me choose who would die…) Lied (to the family about…, status of $ books, # of patients seen, statistics, tests, plagiarism, others lied…) Stole (food, money, job, credit for another’s work…) Covered up (botched surgery, allowed perjury, broken confidentiality, friendly fire, embezzlement…) Betrayed (me, others, country, faith, oath, institution, malpractice suits, abused by person of trust, conflicting desires in dying situations (Pt/No. K, /medical staff…)

Loss of Confidence & Expectations About One’s Own Moral Behavior… “I Can’t Believe I…” 1. Shot/Killed (an unarmed person, a fellow athlete, friendly fire, a patient w/wrong diagnosis/med, innocent inmate, our unborn child, “Sophie’s Choice”…) 2. Lied (to the patient/family about…, about status of $ on books, # of patients seen, statistics, tests, plagiarism…) 3. Stole (food, money, job, identity, abducted a child, his/her spouse, reputation…) 4. Covered up (botched surgery, allowed perjury, broken confidentiality, affair, embezzlement…)

When Two Beliefs Collide & One Has to be Chosen 1. Kill or be killed (children, women, robber, non-combatants, rapist, criminal, enemy…) 2. “Everyone deserves” vs. resources…medical care, triage, but patient caused. . , this is a “bad person, ” transplant, immigration vs. safety/resources; housing & food, legal defense, protection…) 3. Survival…steal, lie, trade sex/money/power 4. Religious Beliefs vs. Reality 5. Legal Requirements vs. Religious Beliefs 6. Quality vs, Efficiency

PTSD and Moral Injury PTSD is a fear-victim reaction to extreme conditions that damage amygdala and hippocampus (limbic brain) Moral Injury requires a healthy prefrontal cortex where empathy and moral thinking occur.

Disruption of Two Important Relationships 1. PTSD disrupts the relationship to the world when logical thinking becomes unreliable 2. Moral Injury disrupts relationship with the self when inner moral core is doubted Brock & Keizer webinar

Three Spiritual Maladies 1. Soul Wounds: use spiritual language to describe the cost of war/the event to themselves: “I died spiritually, ” “they (the event/ situation/war) stole my soul, ” “there is no God, ” “I saw evil firsthand, ” “I descended into hell, ” etc. 2. The Violated Conscience: a confusion/violation of one’s ethics & morality; esp. if one behaved amorally/ immorally • • Guilt and shame fester and can erupt yrs later Suicide may seem the only way out; #1 predictor = guilt & shame 3. Deep Grief: specific feelings, thoughts, intensions, actions & sensations resulting from multiple losses • • • Mild losses-missed anniversaries, births, home crises, etc. Severe losses—death, limb, mental capacity, hope, faith, relationships, etc. Delayed grieving until later/home—if then Tangled web of trauma, depression and grief Sippola et. al.

Spiritual Maladies of Combat • Some causes of trauma have spiritual roots: • others. • Split min. decisions—all affect & are affected by one’s beliefs and values on self-preservation and an obligation to defend/protect self/others While the horrors of war may not be the rule, they aren’t uncommon either Some emerge spiritually intact & grow stronger Some emerge broken and in despair, with a loss of hope & meaning, succumb to nihilism--their “give a shit” is broken • • • Living w/ the threat of being killed, killing others, not killing

Some Cultures and Moral Injury • Military/police cultures foster moral and ethical codes of conduct (Integrity, honor, duty, self-sacrifice…) • Being violent and killing are expected parts of the job • Members expect & are trained & prepared for violence and killing • Still, even prescribed / “righteous” killing or violence may have a lasting impact • Most members can assimilate what they see and do because they are trained for it Brock & Keizer webinar

Why Combat Trauma Affects the Soul • War is essentially a spiritual undertaking that is virtually always justified by transcendent values • When troops go to war, they are almost inevitably disillusioned, especially those who joined for transcendent values • In combat, troops are constantly put into morally ambiguous situations • Morality is the foundation for all other values, and combat often challenges the moral values they have been taught/believe Langer, R (2009, October)

Moral Repair Process 1. Dialogue with Benevolent Spiritual/Moral Authority • Practice deep, nonjudgmental listening to experiences that precipitated moral injury • • Offer benevolent understanding of moral struggle Affirm core moral beliefs that emerge 2. Reparation & Forgiveness • • Discuss how reparation might occur in the current context • Model self-forgiveness and repair of harm—process of making amends • Help them find decency & goodness in working for & service to others Offer support for self-forgiveness or forgiveness from others

3. Fostering Reconnection in Community • • • Discuss current relationships • • Develop coping strategies for inevitable stress & conflicts Assist to form deeper relationships (individual & community) Develop strategies for openness & sharing vulnerability & struggle Explore broken relationships that can be repaired in some way 4. Long-Term Planning • Encourage reflection on the future • • What would they like to see for themselves? • What values, beliefs, communities, etc. will continue to sustain them moving forward? • How will they cope with the challenges, setbacks, and revisiting of war experiences that will come? Who will continue to matter to them; how can relationships be supported & enhanced? B. T. Litz, et. al.

Partnering for Recovery

Importance of Recovery in Communities to Soul Repair & Spiritual Recovery • Lamentation for losses • Forgiveness; amends • Transformation; renewal • Reconstruct moral core values and self-worth • Rituals of loss • Support for loss • Amends through service to others • Spiritual Forgiveness and Discipleship in one’s faith tradition • Absolution (letting go and moving on) • Transformation & Renewal • Reconstruction of moral meaning, choices, place in life • Participate in meaning-making in midst of moral ambiguity & difficult choices Brock & Keizer webinar

• Listen with a non-judgmental ear & be patient • Relate to the person—not the politics, rules, expectations • ASK them what they want/need • Offer realistic encouragement—not your fault, ok to • • falter… Normalize getting help—“It takes the courage of a warrior” Encourage others outside the institution to provide safe places of help (clergy, counselors, medical. legal) Peer to Peer support: (Vietnam w/new vets) Understand the issues involved in COSR, PTSD, MST, TBI, secondary trauma, survivor guilt & hero shame, etc. Help them find their own meaning and “new normal” Offer or resource education and support for families Rituals of faith, poems of lament, writing their story

Conversations That Can Heal: • • BEGIN with: “Only Moral People can have a moral wound!” Acknowledge your unknowing; the sacredness of their story • “I wasn’t there, & may never understand: but I want to hear you” • “I imagine war/this impacted you in important ways? Do you want to tell me? ” • Offer Open Compassionate Presence—not advice! • • • Give the person time to open up. • Watch out for anniversary dates & triggers (smells/sounds/feelings) Balance a negative “Internal Working Model” with the “Gray” and the “AND” reframing • “What were your options/choices in that split second? ” • The new normal—no more “Garden of Eden, ” lost innocence Be a non-judgmental alternative to self-condemnation and shame • Reframe from “What I did” to “What we [humans] do. ”

Interventions That Can Harm • • • Focusing on our needs vs. needs and timing of the care recipient • Presuming/working towards becoming “normal” overnight—give up survival skills that worked somewhere else • • • Not sharing your confidentiality boundaries upfront • • Misconstruing “forgiving” with “forgetting”—pushing too soon • • Large hero celebrations & praise can backfire Creating an overdependence on you Presuming being glad crisis is past (to be “home, ” “off duty, ” a lesser job, loved one in a better place…) Asking “voyeuristic” questions (killed, been blown up/other) Pushing disclosure before the PTSD/depression addressed = higher suicide risk Rites of confession when one is not prepared, timing is forced and/or cheap forgiveness/grace is offered Pushing your own feelings/attitudes/values/beliefs • Presuming forgiveness needed for having done/not done something

RESOURCES (for assisting military) v. Resources for Clergy/Spiritual Care Givers • What you need to know to help vets in your communities come all the way home (includes web resources): http: //www. mirecc. va. gov/ docs/ visn 6/Clergy. Page. pdf • Military resource for local clergy: http: // 134. 11. 73. 3/ documents/ Resources%20 for%20 America's%20 Clergy_9%204%202008_High. Res_2_sided_print. p df v. Combat-Related Mental Illness and Treatment • Fact sheets on helps w/ post-deployment concerns PTSD: • • • http: //www. sanfrancisco. va. gov/docs/welcome_home_guide. pdf http: // ajp. psychiatryonline. org/cgi/reprint/163/4/586. pdf http: //www. bu. edu/ssw/research/social/pdf/Moral%20 Injury%20 CPR. doc http: //www. ptsd. va. gov/professional/pages/tgs-treatment-iraq-war. asp http: //www. ptsd. va. gov/professional/pages/ptsd-suicide. asp http: //www. defense. gov/releases/release. aspx? releaseid=11015.

v. Coming Home: Family and Military Personnel Self-Help 1. SAMHSA brochure on the Recovery model: http: // download. ncadi. samhsa. gov/ken/pdf/SMA 05 -4129/trifold. pdf 2. VA guide on post-deployment readjustment and addressing PTSD: http: //www. ptsd. va. gov/public/reintegration/guide-pdf/ Family. Guide. pdf 3. A PTSD Exercise: http: //www. patriotoutreach. org/index. html#monaco_testimonial 4. VA guide for military personnel on post-deployment readjustment: • http: // www. ptsd. va. gov/public/reintegration/guide-pdf/SMGuide. pdf • http: //hand 2 handcontact. org/Warning. Signs. War. Veterans. pdf • A soldier’s-eye view: http: //www. ptsdasoldierspective. com/2007/12/ combat-values-link-page. html

v. Addressing Needs of Specific Populations: • VA link to videos that address issues related to significant sub-groups (e. g. , Latino, Asian-American, Native American, and female veterans): http: //www. ptsd. va. gov/public/videos/list-videos. asp • “When Mommy Comes Marching Home” – Incl. military sexual trauma: http: //www. historyplace. com/pointsofview/marching-home. htm • “Traumatic Grief in Military Children: Information for Medical Providers” http: //www. nctsn. org/nctsn_assets/pdfs/military_grief_medical. pdf • PTSD and Criminal Behavior, citing examples related to combat PTSD: http: //ncptsd. kattare. com/ncmain/ncdocs/fact_shts/fs_legal. html? printab le-template=factsheethe military and MS v How the Community Can Help: • • http: //www. army. mil/community/downloads/CC 101. pdf http: //www. hand 2 handcontact. org/stuff. asp http: //www. giveanhour. org/skins

• For military leaders to build their troops’ resilience: • http: //www. dtic. mil/cgi-bin/Get. TRDoc? AD =ADA 472734& Location = U 2&doc=Get. TRDoc. pdf • http: //www. dtic. mil/cgibin/Get. TRDoc? AD=ADA 472734&Location=U 2&do c=Get. TRDoc. pdf • On veterans’ need to talk about the moral impact of having killed: http: //www. nytimes. com/2010/02/14/us/14 killing. html? hpw • Dr. Ilona Meagher’s (Moving a Nation to Care author) website page: • “The Real Cost of the War: Why is the U. S. ignoring battlescarred Soldiers? A special report. ” http: //www. patriotoutreach http: //ptsdcombat. blogspot. com/2007/03/war-list-oefoif-statistics. html . org/cost_ of war. html • Volunteering in the community: http: //www. servicenation. org/pages/ • Moral wounds of war: http: //www. britesoulrepair. org mission-serve 1 http: //www. conscienceinwar. org

Books, Articles & Lectures Armstrong, Keith, Suzanne Best, & Paula Domenici (2005). Courage After Fire: Coping Strategies for Troops Returning from Iraq and Afghanistan & Their Families. CA: Ulysses Press. The Army Chaplaincy. “Spiritual resilience: Renewing the soldier’s mind”, Professional Bulletin of the Unit Ministry Team, Spiritual Summer-Fall 2009. Brock, Rita Nakashima and Herman Keizer, Jr. Worship That Addresses Needs of Veterans with Moral Injury (webinar). Cantrell, Bridget C. (2009). Souls Under Siege: The Effects of Multiple Troop Deployments-and How to Weather the Storm. Seattle: Word. Smith Books, LLC. Carr, C. (2009). Spiritual care for combat veterans. Lecture presented at the CO/WY Association of Professional Chaplains fall training seminar, Centennial, CO. Davis, Richard (2005). “After the war: An insiders look”. The Officer. Herman, Judith Lewis (1997). Trauma and Recovery: The Aftermath of Violence – from Domestic Abuse to Political Terror. NY: Basic. Books. Grossman, Dave & Loren W. Christiansen (2008). On Combat. IL: Warrior Science Publications. Kudler, H. (2009, October). Veterans on campus: Lessons learned and questions for the future. Lecture presented at the Governor's Forum on Campus Mental Health, Breckenridge, CO. Langer, R. (2009, October). A brief overview of combat PTSD. Lecture presented at the Governor's Forum on Campus Mental Health, Breckenridge, CO.

B. T. Litz, N. Stein, E. Delaney, L. Lebowittz, W. P. Nash, C. Silva & S. Maguen “Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy, ” (Dec. 2009) Clinical Psychology Review, 29, 695 -706 Matsakis, Aphrodite (2007). Back from the Front: Combat Trauma, Love, and the Family. MD: Sindron Institute Press. Mc. Cauley, Carol (2010, April). Soulcare of the Wounded Warrior: Healing Warzone Guilt and Shame in Community. Lecture presented at the Association of Professional Chaplains Conference, Schamburg, Il. Meagher, Ilona (2007). Moving a nation to care—Post-traumatic stress disorder and America’s returning troops. NY: IG Publishing. Ramsey-Lucas, C. (Ed. ) (2009). “Supporting Those who Serve: Ministry with Service Members, Veterans, and Their Families”. The Christian Citizen, 3. Sippola, J. , Blumenshine, A. , Tubesing, D. , Yancy, V. (2009) Welcome them home— Help them Heal. MN: Whole Person Associates, Inc. Tanielian, T. , Jaycox, L. H. , Schell, T. L. , Marshall, G. N. , Burnham, M. A. , Eibner, C. …The Invisible Wounds Study Team (2008). Invisible wounds of war. CA: The Rand Corporation. Tick, Edward (2005). War and the Soul: Healing Our Nation's Veterans from Post. Traumatic Stress Disorder. IL: Quest Books. Thompson, D. A. , Wetterstrom, D. (2009). Beyond the yellow ribbon — Ministering to returning combat veterans. TN: Abingdon Press. Van der Kolk, B. A. , Roth, S. , Pelcovitz, D. , Sunday, S. , & Spinazzola, J. (2005). “The disorders of extreme stress: The empirical foundation of a complex adaptation to trauma”. Journal of Traumatic Stress, 18, 389– 399.

Additional Resources • Letters from a Fort Lewis Brig, Sgt. Kevin Benderman • Packing Inferno, Tyler Boudreau • Military Life: the Psychology of Serving in Peace and Combat, Thomas W. Britt, Carl Andrew Castro, & Amy B. Adler, Eds. • Soul Repair, Rita Nakashima Brock and Gabriella Lettini • The Unfinished War, Walter Capps • Letters from Abu Ghraib, Joshua Casteel • Restoring the Shattered Self, Heather Davediuk Gingrich • Shade It Black, Jess Goodell and John Hearn • On Killing, David Grossman

• Counseling Military Families, Lynn K. Hall • Tending the Warrior Soul, Louis Harrison • What It Is Like to Go to War, Karl Marlantes • Road from Ar Ramadhi, Camilo Mejia • Until Tuesday, Luis Carlos Montalvan • Love our Vets, Welby O’Brien • The Yellow Birds, Kevin Powers • Achilles in Vietnam, Jonathan Shay • The Untold War, Nancy Sherman • The Moral Treatment of Returning Warriors in Early and Modern Times, Bernard Vercamp

Film Resources • Apocalypse Now, 1979, During the Vietnam War, Captain Willard is sent on a • Faith and Doubt at Ground Zero, 2002, this PBS documentary examines the • • dangerous mission into Cambodia to assassinate a renegade colonel who has set himself up as a god among a local tribe. most profound of all religious questions: If God exists, and God is good, how does such evil exist in the world? Through interviews with pastors, priests and rabbis as well as with homemakers and cab drivers and fire fighters, this question and the question about how ones faith is strengthened or weakened as a result of 9/11 are examined. The documentary takes no position on these questions - it simply raises them and allows others to answer for themselves with no judgment or comment. The Ground Truth, 2006, ordinary troops military experience & the struggle to reintegrate with families and communities. The Iraq conflict is fought by the soldiers returning with personal demons, an uncomprehending public, and an indifferent government. Each soldier becomes a new kind of hero, to other vets, wielding the most powerful weapon of all - the truth. Soldiers of Conscience, 2007, transcends politics & explores the tension between spiritual values and military orders. It follows the stories of both conscientious objectors & those who criticize them. Through this clash of views, surprising common ground is : all soldiers are "soldiers of conscience, " torn between the demands of duty & conscience. Taxi to the Dark Side, 2007, USA documentary in-depth look at the torture practices of the US in Afghanistan, Iraq & Guantanamo Bay, focusing on an innocent taxi driver in Afghanistan who was tortured & killed in 2002. Lioness, 2008 PBS film, story of the 1 st US women to be sent into direct ground combat.

• Stop-Loss, 2008, A veteran soldier returns from a completed tour in Iraq, to find his • Restrepo, 2010 documentary, a year with one platoon in the Afghan's deadliest • The Dry Land, 2010, U. S. soldier returning home from war struggles to reconcile life turned upside down when he is arbitrarily ordered to return to field duty by the USA. valley. his experiences with the life and family he left in TX. • The Invisible War, 2012 investigative documentary about the epidemic of rape of • The Railway Man, 2013, British/Australian-made war film, a British officer, who • Hacksaw Ridge, 2016, uses a real-life pacifist's legacy to lay the groundwork for a • Eye in the Sky, 2016, Watching battle organized at arm's length is a strange and soldiers within the US military. was tormented as a WWII Japanese labor camp POW sets out to confront captor. gripping wartime tribute to faith, valor, and the courage of remaining true to one's convictions. surreal experience, steeped in dread. The moral implications of modern drone warfare confronted in tackling an ethical dilemma in a thought-provoking suspenseful story. .