1. Moral Injury or Soul Wounding in Soldiers Returning from War
Erv Janssen, M.D.
Jim Lyall, MPA, CIRS
Dr. Lanny Endicott, LCSW, LMFT

2. Presentation Agenda: 1. BASIC CONCEPTS RELATED TO MORAL/SOUL INJURY
2. DIFFERENT FROM:
Post Traumatic Stress Disorder - PTSD
Traumatic Brain Injury - TBI
3. HEALING PROCESS AFTER MORAL/SOUL INJURY
4. WALKING WITH THE WOUNDED VETERAN
5. EXPLORE, DEVELOP, AND LEARN ABOUT THE HEALING PROCESS THAT BEST SUITS THE NEEDS AND RESOURCES AVAILABLE LOCALLY

3. SILENT WOUNDS OF WAR A. MORAL/SOUL INJURY
A. MORAL/SOUL INJURY
B. POST TRAUMATIC STRESS DISORDER (PTSD)
C. TRAUMATIC BRAIN INJURY (TBI)

4. MORAL/SOUL INJURY

5. RESULTS FROM EXPERIENCES: Perpetrating acts Failing to prevent acts
MORAL INJURY
RESULTS FROM EXPERIENCES:
Perpetrating acts
Failing to prevent acts
Bearing witness to or learning about acts
…….that transgress deeply held moral beliefs and expectations.
THE ACT OF TRANSGRESSION:
That severely and abruptly contradicts rules or codes of conduct during the event.

6. MORAL INJURY INJURY ONLY POSSIBLE IF ACTS OF TRANSGRESSION:
PRODUCE CONFLICT FOR THE INDIVIDUAL
ARE A RESULT OF AN INTACT MORAL BELIEF SYSTEM

7. MORAL INJURY
THOSE WITH A SOCIOPATHIC DISORDER DO NOT LIKELY EXPERIENCE MORAL INJURY
LACK A MORAL CONSCIENCE

9. EMOTIONS RELATED TO MORAL BELIEFS:
GUILT:
A PAINFUL AND MOTIVATING COGNITIVE AND EMOTIONAL EXPERIENCE; “I did something wrong.”
ASSOCIATED WITH DECREASED LIKELIHOOD OF PARTICIPATING IN RISKY OR ILLEGAL BEHAVIOR

10. EMOTIONS RELATED TO MORAL BELIEFS:
2. SHAME:
GLOBAL EVALUATIONS OF THE SELF: “I’m a bad person.”
TENDENCY TO AVOID AND WITHDRAW
RESULTS IN MORE TOXIC INTERPERSONAL ISSUES
ANGER
Moral injury and moral repair in war veterans: A preliminary model and intervention strategy; Brett T. Litz; Nathan Stein; Eileen Delaney, Leslie Lebowitz, William Nash, Caroline Silva, Shira Maguen; Clinical Psychology Review 29 (2009) (p. 699)

11. EMOTIONS RELATED TO MORAL BELIEFS:
2. SHAME: (continued)
DECREASED EMPATHY FOR OTHERS
MORE DEVASTATING LIFE CHANGES
RELATED TO A FEELING THEY HAD COMMITTED PERSONAL AFFRONT AGAINST GOD
EXPERIENCED THIS AS SIN

12. EMOTIONS RELATED TO MORAL BELIEFS
SHAME MAY BE A MORE INTEGRAL PART
OF MORAL INJURY
MAY LEAD TO EXTENSIVE WITHDRAWAL
REINFORCING A FEELING OF CENSURE
AND REJECTION
AND, RUPTURE OF TRUST?
Moral injury and moral repair in war veterans: A preliminary model and intervention strategy; Brett T. Litz; Nathan Stein; Eileen Delaney, Leslie Lebowitz, William Nash, Caroline Silva, Shira Maguen; Clinical Psychology Review 29 (2009) (p. 699)

13. WITHOUT RESOLUTION AND HEALING:
ANXIETY, DEPRESSION, DEMORALIZATION,
SLEEP DISORDERS?
IMPULSE PROBLEMS?
ANGER?
4. NUMBING?
5. SELF-HARMING, SELF-HANDICAPPING?
6. MAY COME YEARS LATER?
Moral injury and moral repair in war veterans: A preliminary model and intervention strategy; Brett T. Litz; Nathan Stein; Eileen Delaney, Leslie Lebowitz, William Nash, Caroline Silva, Shira Maguen; Clinical Psychology Review 29 (2009) (p. 699)

14. MORAL INJURY
NOT:
NOT A NEW ISSUE: HOMER IN THE ILIAD AND THE ODYSSEY (ANCIENT 8th CENTURY BC GREECE)
NOT POSTTRAUMATIC STRESS DISORDER (PTSD)
HOWEVER:
ARE FREQUENTLY EXPERIENCED TOGETHER
Odysseus in America: Combat Trauma and the Trials of Homecoming, Jonathan Shay, M.D., Ph.D.; ©2002, Scribner (p. XI, XV, XVI, 5, 33)

15. POST TRAUMATIC STRESS DISORDER “PTSD”

16. POSTTRAUMATIC STRESS DISORDER (PTSD)
1. A DIAGNOSIS IN THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS
2. RESULTS FROM EXPOSURE TO ACTUAL OR THREATENED DEATH, SERIOUS INJURY OR SEXUAL VIOLENCE; FEAR BASED
3. DIRECT EXPOSURE, WITNESSING, LEARNING ABOUT, EXPERIENCING REPEATED EXPOSURE TO AVERSIVE DETAILS
Diagnostic and Statistical Manual of Mental Disorders (5th Edition), ©2013, American Psychiatric Association ( p. 271)

17. 1. INTRUSION SYMPTOMS DISTRESSING MEMORIES; FLASHBACKS
PTSD (continued)
1. INTRUSION SYMPTOMS
DISTRESSING MEMORIES; FLASHBACKS
2. AVOIDANCE OF STIMULI ASSOCIATED WITH
THE TRAUMATIC EVENT
AVOID MEMORIES, THOUGHTS, FEELINGS OF EVENT
Diagnostic and Statistical Manual of Mental Disorders (5th Edition), ©2013, American Psychiatric Association (p. 271)

18. PTSD (continued) 3. NEGATIVE ALTERATIONS IN COGNITIONS OR MOOD
INABILITY TO REMEMBER DETAILS
4. MARKED ALTERATIONS IN AROUSAL AND REACTIVITY
IRRITABLE BEHAVIOR; ANGRY OUTBURSTS
RECKLESS/SELF-DESTRUCTIVE BEHAVIOR
HYPERVIGILANCE
EXAGGERATED STARTLE RESPONSE
SLEEP DISTURBANCE

20. TRAUMATIC BRAIN INJURY

21. TRAUMATIC BRAIN INJURY (TBI)
CAUSED BY IMPACT TO THE HEAD RESULTING IN RAPID MOVEMENT OF BRAIN WITHIN THE SKULL
WITH BLAST INJURIES (i.e. from IED) RESULT IN CONCUSSIVE OR PERCUSSIVE DAMAGE
MAY NOT SEE ANY DAMAGE ON DIAGNOSTIC STUDIES (MRI, CT SCAN, ETC.)
DAMAGE INSIDE THE BRAIN CELLS?

22. MORAL INJURY AND PTSD: RELATED TO BRAIN ANATOMY/PHYSIOLOGY

23. FINDING THOSE THAT ARE HURTING…

24. FINDING THOSE WHO ARE HURTING
1. THE VETERAN
2. THE FAMILY
3. “THE CLINICAL SYSTEMS”
4. “THE JUDICIAL SYSTEMS”
5. FAITH COMMUNITIES

25. FINDING THOSE WHO ARE HURTING (continued)
MUST KEEP MORAL INJURY AS A PART OF THE “DIFFERENTIAL DIAGNOSIS” 
ASK IF THE INDIVIDUAL CAN SAY ANYTHING ABOUT SOME OF WHAT THEY EXPERIENCED
OFTEN RELATE BEST TO OTHER VETERANS
REQUIRES A “SAFE ENVIRONMENT”

26. FINDING THOSE WHO ARE HURTING (continued)
“DEEP LISTENING”
SET ASIDE OUR OWN ISSUES
OFFER RESPECT
LISTEN WITHOUT JUDGMENT
LIKELY TO BE A SLOW PROCESS OVER A PERIOD OF TIME

27. TO HELP THE DIALOGUE: MIES Instructions: Please circle a number to indicate how much you agree or disagree with each of the following statements about your experiences at any time since joining the military.
Strongly Disagree
Moderately Disagree
Slightly Disagree
Slightly Agree
Moderately Agree
Strongly Agree
1. I saw things that were morally wrong. 1 2 3 4 5 6
2. I am troubled by having witnessed others' immoral acts.
3. I acted in ways that violated my own moral code or values.
4. I am troubled by having acted in ways that violated my own morals or values.
5. I violated my own morals by failing to do something that I felt I should have done.
6. I am troubled because I violated my morals by failing to do something I felt I should have done.
7. I feel betrayed by leaders who I once trusted.
8. I feel betrayed by fellow service members who I once trusted.
9. I feel betrayed by others outside the U.S. military who I once trusted.

28. MIES - (Moral Injury Events Scale)
Instructions: Please circle a number to indicate how much you agree or disagree with each of the following statements about your experiences at any time since joining the military.
Strongly Disagree
Moderately Disagree
Slightly Disagree
Slightly Agree
Moderately Agree
Strongly Agree
1. I saw things that were morally wrong. 1 2 3 4 5 6
2. I am troubled by having witnessed others' immoral acts.
3. I acted in ways that violated my own moral code or values.
4. I am troubled by having acted in ways that violated my own morals or values.

29. MORAL INJURY EVENTS SCALE
I SAW THINGS THAT WERE MORALLY WRONG.
I AM TROUBLED BY HAVING WITNESSED OTHERS’ IMMORAL ACTS.
I ACTED IN WAYS THAT VIOLATED MY OWN MORAL CODE OR VALUES
I AM TROUBLED BY HAVING ACTED IN WAYS THAT VIOLATED MY OWN MORALS OR VALUES.

30. MORAL INJURY EVENTS SCALE (continued)
I VOLATED MY OWN MORALS BY FAILING TO DO SOMETHING THAT I FELT I SHOULD HAVE DONE.
I AM TROUBLED BECAUSE I VIOLATED MY MORALS BY FAILING TO DO SOMETHING I SHOULD HAVE DONE.
I FEEL BETRAYED BY LEADERS WHO I ONCE TRUSTED.
Psychometric Evaluation of the Moral Injury Events Scale; CAPT William Nash, Teresa L. Marino Carper, Mary Alice Mills, Teresa Au, Abigail Goldsmith, Brett T. Litz; Military Medicine, 178, 6:646, 2013

31. MORAL INJURY EVENTS SCALE (continued)
I FEEL BETRAYED BY FELLOW SERVICE MEMBERS I ONCE TRUSTED.
I FEEL BETRAYED BY OTHERS OUTSIDE THE U.S. MILITARY WHO I ONCE TRUSTED.
Psychometric Evaluation of the Moral Injury Events Scale; CAPT William Nash, Teresa L. Marino Carper, Mary Alice Mills, Teresa Au, Abigail Goldsmith, Brett T. Litz; Military Medicine, 178, 6:646, 2013

32. HEALING AND RECOVERY FROM MORAL INJURY

33. HEALING AND RECOVERY FROM MORAL INJURY
HEALING AND RECOVERY FROM MORAL INJURY REQUIRES A RENEWED SENSE OF LIFE PURPOSE AND SERVICE; “A PROCESS, NOT AN EVENT”
THE MOST DANGEROUS ASPECTS OF MORAL INJURY:
COLLAPSE OF MEANING IN LIFE
LOSS OF A WILL TO LIVE

34. HEALING AND RECOVERY FROM MORAL INJURY
“ADAPTIVE DISCLOSURE”
NOT PUT IN CONTEXT OF THERAPY OR TREATMENT
BASED ON CONCEPT OF COGNITIVE-BEHAVIORAL THERAPY
FORGIVENESS IS CENTRAL TO RECOVERY
MUST ESTABLISH TRUST
Moral Injury: A Mechanism for War-Related Psychological Trauma in Military Family Members; William P. Nash, Brett T. Litz; (Authors Proof); Clinical Child Family Psychological Rev., 2013
Moral injury and moral repair in war veterans: A preliminary model and intervention strategy; Brett T. Litz; Nathan Stein; Eileen Delaney, Leslie Lebowitz, William Nash, Caroline Silva, Shira Maguen; Clinical Psychology Review 29 (2009)

35. HEALING AND RECOVERY FROM MORAL INJURY
INITIALLY USED AT CAMP PENDLETON
ISSUES INCLUDE:
ESTABLISH TRUST
DETAILED DISCLOSURE OF MORALLY INJURIOUS EVENTS
IMAGINAL DIALOGUE WITH A COMPASSIONATE MORAL AUTHORITY
Moral Injury: A Mechanism for War-Related Psychological Trauma in Military Family Members; William P. Nash, Brett T. Litz; (Authors Proof); Clinical Child Family Psychological Rev., 2013
Moral injury and moral repair in war veterans: A preliminary model and intervention strategy; Brett T. Litz; Nathan Stein; Eileen Delaney, Leslie Lebowitz, William Nash, Caroline Silva, Shira Maguen; Clinical Psychology Review 29 (2009)

36. HEALING AND RECOVERY FROM MORAL INJURY
“ADAPTIVE DISCLOSURE”
(continue)
APPORTIONING BLAME
MAKE OR SEEK AMENDS
ACCEPTANCE
FORGIVENESS IS CENTRAL TO RECOVERING FROM MORAL INJURY
Moral Injury: A Mechanism for War-Related Psychological Trauma in Military Family Members; William P. Nash, Brett T. Litz; (Authors Proof); Clinical Child Family Psychological Rev., 2013
Moral injury and moral repair in war veterans: A preliminary model and intervention strategy; Brett T. Litz; Nathan Stein; Eileen Delaney, Leslie Lebowitz, William Nash, Caroline Silva, Shira Maguen; Clinical Psychology Review 29 (2009)

37. THE END

38. HEALING AND RECOVERY FROM MORAL INJURY DR
HEALING AND RECOVERY FROM MORAL INJURY DR./PASTOR RITA BROCK BRITE DIVINITY SCHOOL, TCU POWER POINT, PHILIPS SEMINARY, TULSA, OK MAY (based on ADAPTIVE DISCLOSURE)

39. HEALING AND RECOVERY FROM MORAL INJURY
INDIVIDUAL/SOCIAL DIMENSIONS OF RECOVERY:
Externalizing inner struggle and telling the story
Integrating memory/story into larger picture
Reconnect with estranged others; veterans support systems
Moral Injury and Recovery (PowerPoint); Rita Nakashima Brock and Herman Keizer, Jr., Phillips Seminary; May 2013, Tulsa, OK

40. HEALING AND RECOVERY FROM MORAL INJURY
2. IMAGINAL DIALOGUE WITH A BENEVOLENT MORAL AUTHORITY (Deep, nonjudgmental listening)
OFFER BENEVOLENT UNDERSTANDING OF MORAL STRUGGLE
AFFIRM CORE MORAL BELIEFS THAT EMERGE; DISCUSS THESE
DISCUSS HOW REPARATION MIGHT OCCUR SUPPORT SELF-FORGIVENESS FROM OTHERS

41. HEALING AND RECOVERY FROM MORAL INJURY
3. REPARATION AND FORGIVENESS
OFFER OPPORTUNITIES FOR SERVICE TO OTHERS AND WAYS TO MAKE A POSITIVE CONTRIBUTION TO OTHERS
SUPPORT VETERANS IN FINDING DECENCY AND GOODNESS IN WORKING FOR OTHERS
MODEL SELF-FORGIVENESS AND REPAIR OF HARM

42. HEALING AND RECOVERY FROM MORAL INJURY
4. FOSTERING RECONNECTION
DISCUSS CURRENT RELATIONSHIPS
FORMING DEEPER CONNECTIONS
STRATEGIES FOR GREATER OPENNESS
PERSONAL COPING STRATEGIES
REFLECTION ON BROKEN RELATIONSHIPS THAT CAN BE REPAIRED IN SOME WAY

43. ROLE OF CONGREGATIONS AND COMMUNITIES IN SOUL REPAIR
HELP CONGREGATION AND COMMUNITY RECOGNIZE THEIR ROLE IN SENDING OTHERS INTO HARMS WAY
Soul Repair: Recovery from Moral Injury after War; Rita Nakashima Brock and Gabriella Lettini; ©2012, Beacon Press (p. 110)

44. ROLE OF CONGREGATIONS AND COMMUNITIES IN SOUL REPAIR
SPIRITUAL RECOVERY
a. LAMENTATION (express grief, mourning) FOR LOSSES
b. FORGIVENESS; Amends
c. DISASTER RELIEF WORK
d. PEACE MISSIONS
e. NEIGHBORHOOD SERVICE
e. ABSOLUTION (LETTING GO)

45. ROLE OF CONGREGATIONS AND COMMUNITIES IN SOUL REPAIR
3. RITUALS OF LOSS
COMPLAINT AGAINST GOD
REALIZATION THAT CONVERSATION IS WITH GOD
REMEMBRANCE OF DIVINE LOVE AND FAITHFULNESS
RESTORES GOD TO SOUL
4. TRANSFORMATION AND RENEWAL
RHYTHMS OF LITURGICAL YEAR
VICARIOUS RELIVING OF BAPTISMAL REBIRTH

46. ROLE OF CONGREGATIONS AND COMMUNITIES IN SOUL REPAIR
RECONSTRUCT MORAL CORE VALUES
AND SELF-WORTH
RECOGNITION OF EXISTENCE OF MORAL ORDER
BEHAVIOR AND MORAL CHOICES MAKE SENSE
JOINING NOT WITHDRAWING

47. MORAL INJURY: A SILENT WOUND OF WAR
SUMMARY
MORAL INJURY: A SILENT WOUND OF WAR
Results from experiences that transgress deeply held moral beliefs/expectations.
DIFFERS FROM PTSD
Related to fear, exposure to actual or threatened death, serious injury or sexual violence.
WHEN NOT CONSIDERED IT GOES UNRECOGNIZED AND UNRESOLVED

48. 4. HEALING INVOLVES “COMMUNITY”; “A PROCESS, NOT AN EVENT”
SUMMARY
4. HEALING INVOLVES “COMMUNITY”; “A PROCESS, NOT AN EVENT”
5. IT IS TIMELY FOR PROFESSIONALS TO SYSTEMATICALLY PLAN OUT HOW BEST TO ASSIST OUR VETERANS IN THEIR RETURN

49. Moral Injury or Soul Wounding in Soldiers Returning from War