1. This document contains U.S. Department of Veterans Affairs proprietary business information and may not be reproduced without permission. Ways I Care. Values We live by. Photos of Veterans. Graphic of I CARE support line: Integrity, Commitment, Advocacy, Respect, Excellence. I CARE Department of Veterans Affairs Logo. Logo of Advance. Transforming Potential Into Performance. U.S. Department of Veterans Affairs seal. MORAL INJURY Coping with Interpersonal Dilemmas of Trauma

2. Are PTSD and Moral Injury the Same? Individual’s with PTSD can have moral injury but they are not the same thing. ICARE | Presentation Title Goes Here2

3. One Conceptualization of PTSD & Moral Injury ICARE | Presentation Title Goes Here 3

4. Differences Between PTSD and Moral Injury PTSD PTSD results from a traumatic event, something terrible and scary that you see, hear about, or that happens to you. The individual may feel that they have no control over what is happening. It includes both physiological and emotional responses. MORAL INJURY Moral injury is a constellation of emotional and behavioral responses to the stress of a trauma. The trauma usually includes inaction, taking action or being helpless to act in a situation that violates the individual’s moral beliefs, values and personal ethics, resulting in an intrapersonal dilemma. ICARE | Presentation Title Goes Here4

5. So What is Moral Injury? ICARE | Presentation Title Goes Here5 Working Definition: Moral Injury is brought about by direct personal experience of, bearing witness to, failure to stop, or perpetration of perceived immoral acts, particularly actions that are inhumane, cruel, depraved, or violent, bring about death or suffering to self or others, leading to a existential crisis. (Adapted: Drescher, Foy: 2011)

6. Events that May Lead to Moral Injury Betrayal – Of self, others, trusted civilians or leadership. Disproportionate Violence – Acts of revenge or mistreatment of enemy combatants. Incidents Involving Civilians – Assault, killing of women or children. Within-Rank Violence – Military sexual violence, friendly fire or fragging. ICARE | Presentation Title Goes Here6

7. Internal versus External Attribution of Injury INTERNAL: MORAL INJURY BY SELF Characteristics include: – Humiliated – Sad – Numb – Intense Emotions – Hindsight-Bias/Responsibility – Wrongdoing – Self-Condemnation – Ridge Belief System Unforgivable The more time that passes the more the individual will be convinced they are unforgiveable. EXTERNAL: MORAL INJURY BY OTHERS Characteristics: – Humiliated – Angry – Intense Emotions – Feeling Betrayed – Rigid Belief System Unforgivable ICARE | Presentation Title Goes Here7

8. History and Aspects of Moral Injury ICARE | Presentation Title Goes Here 8 Jonathan Shay first introduced the concept of moral injury. He was a Neuropathologist and following a stroke came to work at the Boston VA where he worked from 1987-2008 He saw the moral injury as an injury to one’s conscience because of a moral transgression resulting in “profound shame.” He did not consider it a disorder, but a injury.

9. Continued: History and 3 Aspects ICARE | Presentation Title Goes Here 9 Psychological: The perceived moral transgression that leads to blame, guilt, shame, anxiety and withdrawal from others resulting in an increased risk of suicide do to demoralization and self-directed violence. Cultural/Social: The recovery process includes “purification” through communalization of the trauma. Spiritual: Focus on moral issues such as anguish, grief, transgressions of moral and ethical beliefs. – Not every individual identifies their trauma as a spiritual problem. Spiritual aspects are a disruption interferes with how one makes meaning of their lives and how they give meaning to the stress related events in their lives (Park, 2005 )

10. The Spiritual Perspective By Guntzel & Warner ICARE | Presentation Title Goes Here 10

11. Treatment Concerns Individuals prone to experiencing moral injury as a psycho-spiritual problem tend to be inflexible in their religious and moral approach to the world. They see values and their beliefs in black and white therefore have difficulty putting their perspective on what is right and wrong in context when situations are ambiguous. The treatment will likely be directed by the emotions experienced and the beliefs system or perspective of the stressor that is the foundation of the moral dilemma. ICARE | Presentation Title Goes Here 11

12. Spiritual Treatment Approaches Treatment interventions depend on what aspect of Moral Injury that is going to be addressed: 1.Spiritual interventions may use: Psycho-Spiritual Developmental Model; Cognitive and Moral Developmental Theories; Theologically Based Model, with a Deity as a Center-Piece. ICARE | Presentation Title Goes Here 12

13. Cultural Treatment 2. Cultural/Social Intervention May Include: 1)Family/Marital therapy; 2)Building Social Relationships in the Community; 3)Vocational Rehabilitation; 4)Developing Hobbies that Include Others ICARE | Presentation Title Goes Here13

14. Psychological Considerations Psychological Perspective and Paradigm: o Focuses on Cognitive Dissonance – When an individual has two belief that contradict each other and the individual is unable to resolve the conflict. o This occurs when the contradicting beliefs are a perceived moral or intrapersonal ethical violation. THE 3 PERSPECTIVES OR ASPECTS OF A MORAL INJURY ARE NOT MUTUALLY EXCLUSIVE AND OFTEN OVERLAP. ICARE | Presentation Title Goes Here 14

15. Healing & Resilience ICARE | Presentation Title Goes Here15 Research has shown that the ability forgive oneself decreases self- condemnation and shame. It also decreases motivation to retaliate against oneself and increases ones motivation to act benevolently towards others. (Litz, Stein, 2009)

16. Considerations - Healing & Resilience INTERNAL ATTRIBUTION OF INJURY Forgiveness – Decrease in rumination trauma – Increase in social functioning and integration – Improved self-concept Restorative Justice/ – Acknowledging act(s) committed – Committing to live differently – Devoting time and energy to heal Willingness to experiment with new coping strategies EXTERNAL ATTRIBUTION IF INJURY Forgiveness – This does not mean the external party accepts responsibility. Forgiveness is so the individual can move on with life. Willingness to try new coping strategies ICARE | Presentation Title Goes Here16

17. Considerations – Healing and Forgiveness Forgiveness is tricky - Veterans can have inappropriate guilt, versus real guilt, which if not confronted can interfere with healing. – Inappropriate Guilt  Taking responsibility for something that was outside one’s own control because that is less scary than accepting the real world and life is that uncontrollable. ( Dr. Irene Harris) This is not work that can just be done by a family member or a friend. ICARE | Presentation Title Goes Here 17

18. Questions ICARE | Presentation Title Goes Here 18

19. Notes& Themes of Research Research indicates killing and experiencing atrocities are a strong predictor of PTSD “Veterans with high combat exposure or more likely to seek out VA services due to guilt and loss of faith than PTSD or lack of social support (In Litz, B.T., Stein N., 2009). ” Rigid, black and white, good vs. evil believe system creates difficulty for individuals to put ambiguous situations that arise in combat in a functional life context  increases likelihood of moral injury. Urban and guerilla warfare create situation that pose challenges to the rules of engagement. ICARE | Presentation Title Goes Here 19

20. References & Recommended Resources Currier, J. M., Drescher, K. D., & Harris, J. I. (2014). Spiritual Functioning Among Veterans Seeking Residential Treatment for PTSD: A Matched Control Group Study. Spirituality in Clinical Practice, 1, 3-15. Drescher, K. D., Foy, D. W., Kelly, C., Leshner, A., Schutz, K., & Litz, B. (2011). An Exploration of the Viability & Usefulness of the Construct of Moral Injury in War Veterans. Traumatology, http://tmt.sagepub.com/content/17/1/8http://tmt.sagepub.com/content/17/1/8 Guntzel, J. S. & Warner, A., (2013). Invisible Injury: Beyond PTSD. Public Radio WBUR & Symbolia, https://www.publicinsightnetwork.org/2013/06/21/invisible-injury- beyond-ptsd-illustrated-story/https://www.publicinsightnetwork.org/2013/06/21/invisible-injury- beyond-ptsd-illustrated-story/ Harris, J. I., Park, C. L., Currier, J. M., Usset, T. J. & Voecks, C. D. (2015). Moral Injury and Psycho-Spiritual Development: Considering the Developmental Context. American Psychological Association,. http://psycnet.apa.org/?&fa=main.doiLanding&doi=10.1037/scp0000045 http://psycnet.apa.org/?&fa=main.doiLanding&doi=10.1037/scp0000045 ICARE | Presentation Title Goes Here 20

21. Reference & Recommended Resources 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 Maugen, S., Litz, B. (2012). Moral Injury in Veterans of War. PTSD Research Quarterly, 23/1, 1-6. National Center for PTSD - http://www.ptsd.va.gov/index.asphttp://www.ptsd.va.gov/index.asp Park, C.L. (2005). Religion as a meaning-making framework in coping with life stress. Journal of Social Issues, 61, 707-729. Sheenivasan, S., Smee, D. E., & Weinberger, L. E., (2014). Moral Injury: A Meaning-Based Model for Iraq/Afghanistan Combat Veterans. The International Forum for Logotherapy, 37, 26-31. Stein, N. R., Mills, M. A., Arditte, K., Mendoza, C., Borah, A. M., Resick, P. A., Litz, B. T., & the STRONG STAR Consortium (2012). A Scheme for Categorizing Traumatic Military Events. http://bmo.sagepub.com or Behavior Modification 36(6) 787-807. http://bmo.sagepub.com ICARE | Presentation Title Goes Here 21