Explores moral injury and includes an example of how meet the spiritual needs of those suffering with moral injury.

1. Caring for Returning Warriors’ Moral
Injuries
Presenter: Martin Montonye, MS, D.Min., ACPE, BCC, Army Veteran
James A. Haley Veterans’ Hospital, Tampa, FL

2. Objectives
Review definitions of moral injury and PTSD strategies
Examine moral repair intervention strategies
Identify future challenges
Thou shall not kill
vs.
Kill, or be killed, or live
with the shame of not
trying…

3. Moral Imperative
• Veterans are entitled to the best quality care
• Served by professionals trained to the extent
possible by modern means
• Care should not be compromised by training
needs
• Make all efforts to familiarize health care
professionals with the ingredients of caring for
those with moral injury
• Training on moral injury conveys a message to
clinicians and community: This is important.

4. Team Approach
Moral
Injury
Trauma
PTSD

5. Warning: Rabbit Holes Ahead
According to the Urban Dictionary:
From Alice in Wonderland. Metaphor for
the conceptual path which is
infinitesimally deep and complex,
venturing too far down is probably not
that great of an idea.
Examples: Truth, values, reality, evil,
trauma, DSM-5 PTSD, forgiveness,
confession, betrayal, hope, positive
psychology, ethics, morals…
You take the red pill and you stay in
Wonderland and I show you how deep
the rabbit hole goes.
- Morpheus, from The Matrix

6. Subtext
“I can’t believe I am doing this.” “I can’t believe I
did that.” “I’m not the sort of person who
performs such actions.”
“All our knowledge has its origins in
perceptions.” Leonardo da Vinci
“Trust can take years to build but only a second
to break.” Author unknown

7. Job 7:13-16
“When I think my bed will comfort me
and my couch will ease my complaint,
even then you frighten me with dreams
and terrify me with visions, so that I prefer
strangling and death, rather than this body of
mine…my days have no meaning.”

8. Suicide Rates Among Veterans
• 18 a day
• 20% of all suicides in nation
• 2005-2007, increase of 26% under 30 yrs. old
• Returning Reservists vs. Active Duty twice as
likely to have mental health problems (42.4% vs.
20.3%)
http://ipsnews.net/news.asp?idnews=49971
http://www.chron.com/disp/story.mpl/editorial/7516062.html

9. Does combat trauma increase a
person's suicide risk?
• Among Veterans, some studies have found
that combat trauma is related to suicide, while
other studies have not.
• Suicide risk in Veterans may be affected by
how intense and how often the combat
trauma was.
http://www.ptsd.va.gov/public/pages/ptsd-suicide.asp

10. Does PTSD increase suicide risk?
Studies show that suicide risk is higher in persons with PTSD. Some
studies link suicide risk in those with PTSD to distressing trauma
memories, anger, and poor control of impulses. Further, suicide risk is
higher for those with PTSD who have certain styles of coping with
stress, such as not expressing feelings.
Research suggests that for Veterans with PTSD, the strongest link to
both suicide attempts and thinking about suicide is guilt related to
combat. Many Veterans have very disturbing thoughts and extreme
guilt about actions taken during times of war. These thoughts can
often overwhelm the Veteran and make it hard for him or her to deal
with the intense feelings.
http://www.ptsd.va.gov/public/pages/ptsd-suicide.asp

11. Posttraumatic stress disorder (PTSD)
• Can occur after experiencing trauma: Sexual
assault, sexual abuse, accidents, physical
assaults, combat, disaster, or witness death or
injury.
• 60% men, 50% women experience one trauma
• 7-8% of population have PTSD at some point
• 11-20% of Veterans of Iraq and Afghanistan;
10% Gulf War; 30% Vietnam.
National Center for PTSD: How Common is PTSD?

12. Criteria for PTSD diagnosis
1. Stressor: exposed to a catastrophic event
2. Intrusive recollection: flashbacks, nightmares, mental
images, emotional responses (panic, dread, grief or
despair), and physiological reactions
3. Avoidance: behavioral strategies to minimize intensity
4. Negative cognitions and mood: persistent alterations in
beliefs or mood
5. Alterations in arousal or reactivity: panic/anxiety
symptoms, hypervigilance
6. Duration: at least one month prior to diagnosis
7. Functional significance: social/occupational distress
8. Exclusion: not due to substance abuse or other illness
National Center for PTSD: PTSD History and Overview

13. PTSD Approved Treatments
• Cognitive Behavioral Therapy (CBT), such as
Cognitive Processing Therapy (CPT)
Prolonged Exposure Therapy (PE)
• Eye Movement Desensitization and Reprocessing
(EDMR)
• Medications called Selective Serotonin Reuptake
Inhibitors (SSRIs)

14. Acceptance &Commitment Therapy
(ACT)
• Accept what is out of personal control and
commit to action that enriches life
• Teaches psychological skills to handle painful
thoughts and feelings; mindfulness skills
• Clarify what is truly important and meaningful
(values) and use that knowledge to guide, inspire
and motivate to set goals and take action
• Process: Cognitive defusion and acceptance; self-
as-context; clarifying values; and committed
action
http://contextualscience.org/act
http://www.ptsd.va.gov/professional/ptsd101/course-modules/ACtherapy.asp

15. What are Morals?
Personal and shared familial,
cultural, societal, and legal rules
for social behavior.
The fundamental assumptions
about how things should work
and how one should behave in
the world.
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 (2009) 695-706

16. Ethics and Morals
Ethics Morals
What are they?: The rules of conduct recognized in respect to a particular class of
human actions or a particular group, culture, etc. It defines how
thing are according to the rules.
Principles or habits with respect to right or wrong conduct. It
defines how things should work according to an individuals' ideals
and principles.
Source: Social system/Military/External Individual/Internal
Why we do it?: Because society /military says it is the right thing to do. Because we believe in something being right or wrong.
What if we don't do it?: We may face peer/societal/military disapproval, or even be fired
from our job.
Doing something against one's morals and principles can have
different effects on different people, they may feel uncomfortable,
remorse, depressed etc.
Flexibility: Ethics are dependent on others for definition. They tend to be
consistent within a certain context, but can vary between contexts.
Usually consistent, although can change if an individual’s beliefs
change.
The "Gray": A person strictly following Ethical Principles may not have any
Morals at all. Likewise, one could violate Ethical Principles within a
given system of rules in order to maintain Moral integrity.
A Moral Person although perhaps bound by a higher covenant, may
choose to follow a code of ethics as it would apply to a system.
"Make it fit"

17. Definitions of Moral Injury
“Betrayal of what’s right by someone who holds
legitimate authority in a high-stakes situation.”
(Shay, 2010)
“Perpetrating, failing to prevent, bearing witness
to, or learning about acts that transgress deeply
held moral beliefs and expectations.” (Litz et al.,
2009)

18. Moral Injury: Then and Now
• First introduced by John Shay in Achilles in
Vietnam (1995) and Odysseus in America
(2002)
• Occurs when:
– Betrayal of what is right
– By legitimate authority (or “I did it” or both)
– High stakes situation

19. • 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 (2009) 695-706
• “Moral injury requires an act of transgression
that severely and abruptly contradicts an
individual’s personal or shared expectation
about the rules or the code of conduct, either
during the event or at some point afterward.”

20. Soul Repair Center, Brite Divinity
School
• Participation in events that challenge core beliefs
or have no clear moral choices, including violating
moral codes of training in a closed system.
• Use of personal agency that violates core moral
beliefs
• 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 meaning system
that supports it.

21. Combat Rules of Engagement

22. Moral Ambiguity

23. Moral Challenges of War
• Reflexive Fire Training
• Dehumanization of Enemy
• Killing
• Survivor Guilt
• Grief
• Encountering and Handling human remains
• Participation in torture or atrocities
• Betrayal by Authorities
• Doubt (uncertainty about goals or mission)
List from Soul Repair Center, Brite Divinity School

24. Multiple Losses
• Closest friends; isolation
• Unit and Closed System
• Role/Identity/Career
• Home and relocating off base
• Financial losses – no jobs for reservists/National Guard
• Family and intimacy – discord and divorce
• Community of support – self/family
• Faith and meaning
• Reason to live
List from Soul Repair Center, Brite Divinity School

25. PTSD and Moral Injury
DSM-5 PTSD Moral Injury
Stressor (A) Exposure to actual or
threatened death, serious
injury or sexual violence
Acts that violate deeply held
[moral] values
Individual’s role at time of
the event
Witness, victim or direct
exposure
Witness, victim [or failed to
prevent]
Intrusion Symptoms (B) YES YES
Avoidance (C) YES YES
Cognition and Moods (D) Persistent fear, horror, anger,
guilt or shame
Guilt, shame or anger
Arousal and Reactivity (E) YES NO
What necessity is lost? Safety Trust, [Self- or other
compassion, forgiveableness,
faith]
Adapted and updated from William P. Nash, M.D., Moral Injury and Moral Repair:
Overview of Constructs and Early Data. Presentation at 13th Annual Force Health
Protection Conference August 12, 2010. Input from Sidney Davis, Kent Drescher,
Kimberly Gronemeyer, Brett Litz, Lowell Kronick, William Nash, Jason Nieuwsma,
Jonathan Shay.

26. VA/DOD Chaplain Survey
• VA/DOD Mental Health Strategy #23
• 11/11-4/12, online survey
• VA Chaplains (n = 440/585): 75%
• Most frequently encountered problems:
– Anxiety, physical health problems, alcohol abuse,
depression, guilt, spiritual struggle understanding
loss/trauma and PTSD.

27. Do you see any reason why a combat
soldier might have moral injury?
• Exercise: Discuss the
following (10 min)
1. Do you see a need for the
concept of moral injury?
2. How would you define
moral injury?
3. As a member of the
treatment team, how do
you understand your role
and when do you know
when to refer to another
team member?

28. Study of Mental Health and Religious
Professionals
• Drescher K.D., Foy D., Kelly C., Leshner A., Schultz
K., and Litz B.T. (2011). An Exploration of the
Viability and Usefulness of the Construct of Moral
Injury in War Veterans. Traumatology 17(I) 8-13.
• Structured interviews with 23 professionals
(mental health, chaplains, academic researchers)
with knowledge of and experience with OIF/OEF
active duty and veterans.

29. Findings
• All endorsed validity of moral injury as a
construct distinct from PTSD
• Leadership betrayal, trusted peers and self;
violence and revenge; harm to civilians and
property
• Misconduct, violence, social alienation and
alienation from self, loss of faith and meaning
• Need diverse intervention approaches
• Helpers: nonjudgmental, listening, normalizing

30. Intervention Strategy
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 (2009)
695-706.
1. Connection
2. Preparation and education
3. Modified exposure component
4. Examination and integration
5. Dialogue with benevolent moral authority
6. Reparation and forgiveness
7. Fostering reconnection
8. Planning for the long haul

31. Outline of 8 Sessions
• Drescher and Ramirez, National Center for PTSD, VA Palo Alto Health Care
System
• Develop of Trauma and Spirituality Support Group in a 60 day residential
PTSD program to last 3 – 4 years
• Topics:
– What is spirituality?
– Making connections
– Spiritual practices
– Theodicy – “problem of evil”
– Hostility and Forgiveness
– Self-forgiveness
– Values
– Making Meaning
From Drescher and Ramirez presentation on “Spirituality and Combat Stress” (undated) National Center for
PTSD, VA Palo Alto Health Care System.

32. Study: Guilt, shame, and suicide risk in
a military clinical population
• National Center for Veterans’ Studies, University
of Utah.
• Aim: To understand the relationships among guilt,
shame, moral injury, and suicide risk
• Investigating the experience of shame, guilt,
moral injury, and trauma among active duty
military personnel receiving mental health care at
several military clinics, and determine the
interrelationship of these variables with suicide
risk.

33. Interventions for Moral Injury
Nash, P., Litz, B. T. (unpublished). Moral Injury: A
Mechanism for War-Related Psychological
Trauma in Military Family Members. Clinical
Child and Family Psychology Review. DOI
10.1007/s10567-013-0146-y.
• Adaptive Disclosure
• Dialog with a Compassionate Moral Authority

34. JAHVH and Moral Injury
• 6 – week group in PTSD program
• Conducted by Chaplain Cynthia Haynes, 2013
Resident in PTSD Group, 20 – 30 Veterans
• Topics, exercises and prayers:
– Introduction to Moral Injury
– Symptoms (awareness)
– Meditation
– Discerning reality
– Spiritual blocks
– Power of Words/self-messages
– Ritual and forgiveness

35. JAHVH Pre- and Post
1. Things I saw or experienced during the war left me feeling
betrayed
2. I did things during the war that went against my personal
values or spiritual beliefs
3. I saw or knew about the taking of innocent life
4. I was involved in violations of rules of engagement
5. I feel regret for being involved in the death of innocent people
6. I feel guilt over failing to save the life of someone in the war
7. I feel guilt for surviving when others did not
8. I saw or was involved with the death of children
9. I saw of was involved with friendly fire incidents
10. I lost my identity during the war

36. JAHVH Pre- and Post
11. I lost the sense of what was right or wrong during the war
12. I did things that I said I would never do
13. I feel shame because of what I went through during the war
14. I felt abandoned by God during the war and afterwards
15. I feel as though God can not forgive me for what I did
16. I cannot forgive myself
17. Fear still grips me
18. I felt let down by God
19. I have a lot of hatred in my heart because of the war
20. I felt like a monster for what I did
(Adapted from Jason Nieuwsma’s VISN 6 MIRECC scale, Duke University Medical
Center)

37. JAHVH Results
• 13 Veterans participated in healing ritual at
local congregation and completed post-test.
• Significant reduction in scales related to guilt,
shame, feeling abandoned, forgiveness and
hatred.
• Comments from participants included did not
like being labeled having PTSD or therapeutic
techniques. Underlying need for forgiveness.

38. Faith Community Support
• Lamentation for losses – rituals that hold complex
feelings, complaints, remembrance and restore.
• Support for loss – amends through service,
forgiveness and absolution.
• Transformation and Renewal – liturgical year,
sacramental structure of life and reenactment of
sacred stories of redemption here and now.
• Reconstruction – moral order, system of meaning,
moral choices, engagement, meaning-making.
List from Soul Repair Center, Brite Divinity School

39. Moral Repair
• Education around how military culture differs from
civilian life
• Explore variety of intervention strategies
• Improve listening skills (suffering stories)
• Nuanced theology vs. moralism
• Worship that heals wounds of war
• Pray/meditate together
• Start a discussion
• Moral authorities may have unique abilities to forgive
or encourage forgiveness
• Refer – Refer – Refer – Refer - Refer

40. Future Challenges
• Challenge for care-givers to hear about events
• Challenge for Veterans to discuss guilt/shame
producing events
• Traditional exposure therapy alone may not be helpful
• Some care-givers are not moral authorities
• Limited tools available to overcome obstacle to
healing: forgiveness
• Compassion toward self and others may be nearly
incompatible with the warrior ethos (William Nash)

41. Thank You!

42. Resources
Beyond PTSD to “moral injury” http://www.publicinsightnetwork.org/2013/02/19/beyond-ptsd-to-moral-injury/
Moral Injury in the Context of War http://www.ptsd.va.gov/professional/pages/moral_injury_at_war.asp
Moral Injury: Soul Repair Center http://www.britesoulrepair.org
National Center for PTSD HTTP://WWW.PTSD.VA.GOV/
PSALMS OF LAMENT: 12, 44, 60, 74, 79, 80, 83, 85, 90, 94, 123, 126, 129
Betrayal in Literature:
The End of the Affair, Graham Greene
The Remains of the Day, Kazuo Ishiguro
The Screwtape Letters, C.S. Lewis
King Lear, Shakespeare
A Thousand Acres, Jane Smiley
The Age of innocence, Edith Wharton
Recommended Resources from The Soul Center:
Letters from Fort Lewis Brig, Sgt. Kevin Benderman
Packing Inferno, Tyler Boudreau
Soul Repair, Rita Nakashima Brock and Gabriella Lettini
The Unfinished War, Walter Capps

43. Resources
Letters from Abu Ghraib, Joshua Casteel
On Killing, David Grossman
Shade It Black, Jess Goodell and John Hearn
What It Is Like to go to War, Karl Marlantes
Road from Ar Ramadhi, Camilo Mejia
Until Tuesday, Luis Carlos Montalvan
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
Films:
Soldiers of Conscience
The Ground Truth
The Invisible War
Lioness
Restrepo
Stop-Loss
Taxi to the Dark Site

44. Moral Injury Bibliography: Summer
2013 by Kent Drescher
• Currier, J.M., Holland, J.M., Drescher, K., & Foy, D. (in press). Moral Injury Questionnaire – Military Version: Initial Psychometric
Evaluation in a Community Sample. Clinical Psychology & Psychotherapy.
• Drescher, K. D., & Foy, D. W. (2008). When They Come Home: Posttraumatic Stress, Moral Injury, and Spiritual Consequences for
Veterans. Reflective Practice: Formation and Supervision in Ministry, 28, 85–102.
• Drescher, K. D., Foy, D. W., Kelly, C., Leshner, A., Schutz, K., & Litz, B. (2011). An Exploration of the Viability and Usefulness of the
Construct of Moral Injury in War Veterans. Traumatology, 17(1), 8–13. doi:10.1177/1534765610395615
• Drescher, K. D., NIEUWSMA, J. A., & Swales, P. (2013). Morality and Moral Injury: Insights from Theology and Health Science. Reflective
Practice: Formation and Supervision in Ministry, 33, 1–10.
• Flipse-Vargas, A., Hanson, T., Kraus, D., Drescher, K., & Foy, D. W. (2013). Moral Injury Themes in Combat Veterans’ Narrative
Responses From the National Vietnam Veterans’ Readjustment Study. Traumatology, 1–8. doi:10.1177/1534765613476099
• Gray, M. J., Schorr, Y., Nash, W., Lebowitz, L., Amidon, A., Lansing, A., et al. (2011). Adaptive Disclosure: An open trial of a novel
exposure-based intervention for service members with combat-related psychological stress injuries. Behavior Therapy, 1–9.
doi:10.1016/j.beth.2011.09.001
• Kinghorn, W. (2012). Combat Trauma and Moral Fragmentation: A Theological Account of Moral Injury. Journal of the Society of
Christian Ethics, 32(2), 57–74.
• 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(8), 695–706. doi:10.1016/j.cpr.2009.07.003
• Maguen, S., & Litz, B. T. (2012). Moral Injury in Veterans of War. PTSD Research Quarterly, 1–3.
• Nash, W. P., & Litz, B. T. (2013). Moral Injury: A Mechanism for War-Related Psychological Trauma in Military Family Members. Clinical
Child and Family Psychology Review. doi:10.1007/s10567-013-0146-y
• Nash, W. P., Marino Carper, T. L., Mills, M. A., Au, T., Goldsmith, A., & Litz, B. T. (2013). Psychometric evaluation of the moral injury
events scale. MILITARY MEDICINE,, 178(6), 646–652. doi:10.7205/MILMED-D-13-00017
• Stein, N. R., Mills, M. A., Arditte, K., Mendoza, C., Borah, A. M., Resick, P. A., & Litz, B. T. (2012). A Scheme for Categorizing Traumatic
Military Events. Behavior Modification. doi:10.1177/0145445512446945
• Worthington, E., & Langberg, D. (2012). Religious considerations and self-forgiveness in treating complex trauma and moral injury in
present and former soldiers. Journal of Psychology and Theology, 40(4), 274–288.