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Annotated Bibliography of Books and Web Resources About Moral Injury

September 7, 2018 by Rx0puqi Leave a Comment

Books About Moral Injury and Resilience After Moral Injury

Boudreau, Tyler E. Packing Inferno: The Unmaking of a Marine. An autobiographical account of an Iraq veteran’s growing awareness of his own moral injury and what he did about it. Boudreau’s superb prose will give you a visceral taste of combat and its moral ambiguities.

Burke-Harris, Nadine. The Deepest Well. This book is about the long term health damage caused by ACES, adverse childhood experiences. I include it in this bibliography for two reasons: 1) because some researchers suspect that the veterans who have the most difficulty adjusting with resilience to PTS were already severely traumatized as children. (In the brain and body, injury inflicted by trauma is cumulative.) 2) In a late chapter the author makes six recommendations for resiliency which may prove useful for returning veterans.

Chivers, C.J. The Fighters. Stories about six U.S. veterans of the wars in Iraq and Afghanistan. They are: an F-14 pilot, a Green Beret sergeant, a Navy corpsman, a helicopter pilot, an Army infantryman and a Marine lieutenant. Their stories cover the 18 year history of these wars.

Davis, Thomas C. Double Exposure: A Veteran Returns to Vietnam. In this Kindle ebook the author recalls his own moral injury which wasn’t apparent to him until after the end of the war. Religious faith was important in his recovery.

Dean, Chuck. Nam Vet: Making Peace With Your Past. This is a self-help guide from one vet to another, written in simple language.

Grossman, Dave. On Killing: The Psychological Cost of Learning to Kill in War and Society, by Lt. Col. Dave Grossman. The author spends considerable ink proving that in past wars many riflemen refused to shoot at the enemy, because they couldn’t bear taking another’s life. This is a challenge to military trainers, but good news about human nature! Grossman examines how training can desensitize soldiers to killing, and how the act of killing can plague them afterwards.

Kingston, Maxine Hong. Veterans of War, Veterans of Peace, a collection of excellent short stories authored by veteran writers, mostly from the Vietnam and Korean wars. The stories are largely hopeful and inspirational.

Marlantes, Karl. What It’s Like to Go to War. Marlantes was a Marine captain in Vietnam. He wrote a fictional best seller called Matterhorn which was informed by his combat experience. This book gives the factual details of that experience.

Meagher, Emmet and Jonathan Shay. Killing from the Inside Out. This author digs deeply into western history to dispute the moral validity of just war theory.

Moon, Zachary. Coming Home: Ministry That Matters With Veterans and Military Families. Guidance for Christian churches who want to help veterans and their families.

Nakashima Brock, Rita. Soul Repair: Recovering From Moral Injury After War. Professor Nakashima Brock has established a Center for Soul Repair at the Brite Theological Seminary, dedicated to research and public education about recovery from moral injury.

Sackett, John G., Major USAF. Guilt Free War: Post Traumatic Stress Disorder and An Ethical Framework for Battlefield Decisions. Moral injury is a challenge to military trainers, he writes. If human beings have an inborn reticence to kill, how can they be trained to perform the job of killing without morally injuring themselves? Major Sackett proposes guidelines for preparing soldiers ahead of time to not hold themselves morally culpable for battlefield decisions they may be forced to make. His book is based on just war theory, which other authors in this bibliography reject.

Sheehan, Dan. Continuing Actions: A Warrior’s Guide to Coming Home. A former combatant who experienced moral injury describes his own road to recovery in a style that will appeal to other warriors.

Sherman, Nancy. Afterwar: Healing the Moral Wounds of Our Soldiers.

Sites, Keven. The Things They Cannot Say. Stories about moral injury told by grunts.

Tick, Edward. Warrior’s Return: Restoring the Soul After War. An early author in the field of moral injury, Tick’s book is based on clinical work with many combatants.

Van der Kolk, Bessel. The Body Keeps the Score: Brain, Mind, and Body Healing of Trauma. Not just about moral injury, but trauma in general, and not just trauma experienced in combat. Van der Kolk explains that all trauma injures the body and the brain, so treatments must address both. He also explains that trauma is cumulative. It is stored in the body, and each new trauma is added to the sum of previous ones. Soldiers who experienced traumas as children have injuries to their bodies and brains which may make it more difficult to recover from more recent traumas. This is a seminal book in the field of PTSD research.

Wood, David. What Have We Done: The Moral Injury of Our Longest Wars, by war correspondent, David Wood. Chronicles his considerations of “moral costs” of the wars in Iraq and Afghanistan.

Yocum, Cecilia. Help for Moral Injury: Strategies and Interventions. A fairly short book with concise descriptions of evidence based treatments helpful for treating veterans with moral injury. It is written for professional psychiatric and medical practitioners, and it involves mainly one-on-one techniques.

Yunger, Sabastian. War. A war correspondent’s deeply honest account of the harrowing experiences of the 2nd Platoon, Battle Company of the 173rd Airborne Brigade in Afghanistan. Yunger organizes his book in three long chapters: Fear, Killing, and Love.

Web Resources On Moral Injury and Resilience After Moral Injury

The very best of these web resources are the last listed, the three articles by war correspondent, David Wood. You might do best to start there.

Arrow, Holly; and Schumacher, William M. “What is moral injury in veterans?” published in The Conversation. A good, brief introduction to moral injury.

Barno, David; and Bensahel, Nora. “How to Talk to a Veteran,” Published by the University of Texas. “Thank you for your service!” may not be a helpful greeting for a veteran troubled by moral injury, because he/she is not proud of what he/she did, and therefore shouldn’t be thanked for it. This article provides guide for what is most helpful in talking with a veteran.

Clear, James “Make More Art: The Health Benefits of Creativity.” Moral injury arises in the top and front of the human brain, the pre-frontal cortex. The non-conscious part of the brain, at the bottom and back, is where trauma hypes-up the fight-or-flight mode of consciousness for self-protection, and the nervous system gets stuck in high gear. That non-conscious part of the brain can be calmed by deep breathing meditation, but also, it seems to this veteran, by making art. Making art is a partly reflective process, but it’s also a not totally conscious one, an intuitive one, we say. So, like deep breathing, making art can be a bridge between the reflective part of the brain and the non-conscious part. This integration brings a peace which neurologically is not yet fully understood.

Cramer, Tom. “Can Spiritual Therapy Heal Your PTSD Symptoms?” Published through the Veterans’ Administration in Virginia. Mentions Dr. Nagy Youssef who is researching how faith communities can help veterans with moral injury.

Dickerson, Caitlin. “On Family Separation, Federal Workers Often Agonized Over Enforcement“, Published in the New York Times. Often moral injury occurs when one feels personally responsible for the death of another human being, or more than one. This author writes that when some I.C.E. employees were ordered to separate migrant children from their parents they suffered moral injury. This is an instance where there was no evident loss of life involved, yet the responsible officials felt morally trapped between a call to follow orders and their own consciences.

Gessler, Paul. “PTSD and Moral Injury Are the Hidden Wounds of Veterans,” a letter to veterans on the campus of Rocky Mountain College. Published under the auspice of Veterans for Peace and the Adult Learning and Veteran Services Office of the college.

Jones, Diana Nelson. “‘Veterans’ Breakfast Club’ offers help to heal from moral injuries.” Published by the Pittsburgh Post Gazette. In her six recommendations for promoting resilience after trauma, author Dr. Nadine Burke-Harris notes (#6) that getting connected to a supportive community is essential. This article illustrates her point.

Kniggendorf, Anne. “Kansas City Veteran and Physician Treats the ‘Moral Injury’ of War Through Poetry.” From an interview at WCUR 89.3 FM.

Mighty Visual (a blogger at Vimeo), video entitled “Hunter in the Blackness: Veterans, Hope and Recovery,” Vietnam vets and younger veterans from the Iraq and Afghanistan Wars talk about their post traumatic stress and moral injury and what’s been helpful to them in recovery.

Press, Eyal. “Wounds of the Drone Warrior,” published in the New York Times Magazine. In his book on the psychological effects of killing David Grossman observes that distance from the enemy tends to decrease a combatant’s moral sensitivity to killing. However, the visual preciseness of recently developed aerial cameras has made it possible for attack drone pilots to see what’s happening to their human targets quite clearly. Some are suffering extreme stress and moral injury in this line of duty.

Talbot, Simon G. and Dean, Wendy. “Physicians Are’t ‘Burning Out’. They’re Suffering From Moral Injury.” Many physicians enter that profession because they have high ideals and want to save lives. But the complicated demands of modern medicine frustrate that desire, and leave some feeling deep moral failure.

Turner, Jon Michael. YouTube video of him testifying at Iraq Veterans Against the War’s Winter Soldier gathering.

Woolston, Chris. “Writing for Therapy Helps Erase Effects of Trauma.” Perhaps the title of this article exaggerates. While writing for most veterans will not erase the effects of trauma, it does help to remove much of the emotional power of troubling memories.

Wood, David. Moral Injury: “The Grunts: Damned If They Kill, Damned If They Don’t.” This is the first of a 3-part series published in the Huffington Post. War correspondent Wood has authored some of most poignant short articles on moral injury available on the web. The second in this series is entitled, “The Recruits: When Right and Wrong Are Hard To Tell Apart.” The final article is “Healing, Can We Treat Moral Wounds?“

Resilience After Trauma, and the Importance of Adequate Sleep

August 26, 2018 by Rx0puqi Leave a Comment

Recommendations for Resilience After Suffering Trauma

Recently I reviewed an excellent book by Dr. Nadine Burke-Harris called The Deepest Well. Dr. Burke-Harris explains how early trauma damages children’s brains, and how this damage degrades not only their mental health but also their physical health long term, even into adulthood. In her concluding chapter she lays out six ways that adults injured by childhood trauma can be more resilient:

Get adequate sleep
Get good nutrition
Get regular exercise
Practice meditation
Get professional mental health treatment if necessary
Connect to a supportive community in order to establish positive social relationships.

These are recommendations for sufferers of many kinds of trauma, including those experienced by military veterans.

The Importance of Getting Adequate Sleep

This IVW blog post offers a learning resource for the first of Dr. Burke-Harris’s recommendations, getting adequate sleep. Many people don’t realize how important this is. That’s why researcher Dr. Matthew Walker published Why We Sleep: Unlocking the Power of Sleep and Dreams. It turns out that for the vast majority of human beings (except for a very few who possess a rare gene) getting from seven to eight hours of sleep a night is essential for maintaining mental and physical health. Sleep cleanses the brain of toxins. It helps to regulate all of the body’s functions. Adequate sleep keeps us on an even keel in so many ways. It helps to regulate our blood sugar and blood pressure, tunes up our immune system, helps us concentrate, improves our memory, calms our nerves and moderates our moods. Scimping on sleep increases the likelihood of developing diabetes, cancers, and dementia. The human brain is the command center for all the organs of our complicated bodies, and adequate sleep is absolutely essential for that command center to run efficiently. Human beings can survive a deprivation of food longer than a depivation of sleep. Staying awake continually for about eleven days will kill you, writes Dr. Walker.

Veterans returning from combat often suffer insomnia. Their nervous systems have been on high alert for so long that they can’t easily be tuned down. So how is a veteran who is suffering from insomnia and disturbing nightmares supposed to obtain adequate sleep? Well, all of Dr. Burke-Harris’s recommendations are interconnected. Getting good nutrition and regular exercise, Dr. Walker explains, will help one sleep better. Taking up meditation will help calm the sympathetic nervous system, that is, the unconscious fight or flight mode of consciousness which living in a theater of war instills. And finally, seeking help from mental health professionals and supportive communities will help a veteran find safety of body and mind.

Whether or not you’re a veteran trying to come home and find calm, you may benefit from reading Why We Sleep. If you’ve been taking sleep for granted and shaving your bed time too thin, stop! Get the refreshment that not just your brain but your whole body needs.

— TCDavis

What I Learned From a Blind Teacher of Senior Writers

August 15, 2018 by Rx0puqi Leave a Comment

This post tells what I learned from a blind teacher of senior writers.

I enjoyed several years of writing and reading in the Brandywine Writers’ Circle, founded by Joan Leof, a Wilmingtonian, but I have never led writers groups. That’s changing. I’m endeavoring now to organize the Interfaith Veterans’ Workgroup Writers and a brand new group among the members of New Beginnings-Next Step, a peer support group of returning citizens from Delaware prisons. I’ve also been asked by IVW members in Milford to help them start a writers’ group there. So I figured I should learn something on the subject!

Googling, the following book called out to me: Writing Out Loud: What a Blind Teacher Learned from Leading a Memoir Class for Seniors. IVW has two blind members, and I and several other IVW members are getting long in the tooth, so it seemed appropriate. The book is an easy and entertaining read, and I learned a lot by noting what the author, Beth Finke, an NPR radio commentator, discovered through trials and a few errors. Here are my ten takeaways:

1) The writers in her groups almost all disliked critique as a teaching method. Some wanted to improve their writing, but her writers’ chief reason for joining a group was to share their personal stories. Above all they wanted to be heard.

2) Prompted by their leader her writers learned things about themselves they hadn’t thought much about before; and sharing their stories helped them connect with others more deeply. Memoir is first and foremost a tool for self-discovery; and the sharing of personal stories in a group serves to root one in community.

3) Often, seniors experience a decline in writing agility. Words come less easily, and it gets harder to recall proper nouns, especially. But in the sharing of stories there is an advantage to many years of experience. There is good reason why seniors’ tales regale, not just because they recount times that have grown quaint, but because they speak wisdom that can only be acquired by enduring and surviving.

4) Short writing prompts are often better than longer ones. Even one-word prompts can be excellent. Describing the writing task too finely binds writers’ imaginations. A smidgeon of a springboard suffices.

5) When starting a writers’ group decide on ground rules and stick by them. If you stray too far from what has been agreed upon you may lose writers’ trust and damage morale.

6) Schedule readings so that authors come well prepared and are not rushed. The group may decide to distribute written copies of the upcoming readings ahead of time. It’s good to hear the written word of course, but some people are visual learners and prefer to see what has been written. For them this makes a more profound impression.

7) If many writers want to read on a given day the group may decide to limit the number of words for each reader. Beth Finke’s limit of 500 words seemed to work well. It did not crimp expression, but rather, challenged writers to boil down their broth to the very essence.

8) Make sure that group members have all the resources they need to participate fully in what the group has decided to do. Resources may include access to writing supplies, a personal computer, connection to the internet, transportation to meetings, and free time to meet.

9) As for the group’s agenda, this could be set well ahead by the leader, with planning input and approval from the group of course; or it could be guided by themes which emerge from hearing shared stories.

10) Veteran writers advise: “Write about what you know best.” Perhaps this is why memoir is the most popular genre for beginning writers. But memoir can be mixed with other genres in the same group, like poetry and fictional short stories, to make a pleasing salad. Encourage whatever genres help your writers express themselves artfully and poignantly, according to their own reckoning.

Grief, Post Traumatic Stress, and Moral Injury

August 4, 2018 by Rx0puqi Leave a Comment

An Interfaith Veterans’ Workgroup member who works in the field of mental health observed that some experts recommend that people who are grieving not resist sadness, but rather, allow themselves to feel it and work through it. She asked whether a similar recommendation has been made for veterans suffering from post traumatic stress and moral injury. Here was my answer:

Regarding your excellent question: Grief is a normal response to a profound loss, felt as deep sadness. Cultures have developed ritualistic responses to the death of a loved one. These help people express their sadness in conventional ways, and the rituals provide a way for people to support each other in their grieving. Typically there are not similar rituals for other kinds of deep losses, such as loss of employment or loss of face. It’s good advice, I think, to counsel people to allow themselves to feel the normal sadness of a profound loss. If one tries to avoid feeling this normal sadness one’s grief may turn into the numbness of a severe depression, and that is a condition more difficult to weather.

Warriors experience post traumatic stress because the primitive part of their brains, (the back and bottom), have been on high alert for an extended period, so they are programmed to respond automatically and instantaneously and aggressively to threats. While they are in a theater of war this ramped-up condition of their nervous systems protects them. Therefore, this condition is not experienced as dysfunctional then. But when warriors return home and try to cope with daily life in a very different set of circumstances the behaviors that protected them are experienced both by themselves and others as highly dysfunctional, e.g. hypervigilance, automatic and oddly aggressive responses to even minor threats, odd reactions to noises, unconscious behaviors such as crossing a street to walk on the inside of a curve, or always choosing a seat in a restaurant that faces the entrance. I have discovered that it isn’t easy to de-program the primitive, non-reflective part of the brain with reflective methods. To bring down a ramped-up nervous system, talk therapy isn’t very useful. The body must be involved. Breathing meditation is one treatment that is working well on the unconscious part of the brain. Other treatments are working too. We’re in an exciting time of trauma treatment research.

Moral injury is a deep wound to one’s conscience due to something one did or failed to do in a line of duty which violated one or more of one’s core values. Many of the instances of moral injury involve loss of life. One holds oneself responsible for someone dying, or being put in life-threatening circumstances, and this grieves one very deeply. Warriors often don’t experience moral injury until they have had time to reflect on what happened in a life-or-death situation. Their warrior training programmed them to react automatically and aggressively, causing them to fire immediately, without thinking, upon a perceived threat. Later, remembering the incident in detail and thinking about its consequences, they may or may not forgive themselves for what they did.

Moral injury may be experienced even when there is no loss of life. (I have changed my view on this. In an earlier post I called killing the root of moral injury, but it isn’t always). In 1975, when Saigon fell to North Vietnamese troops I began to have nightmares, not about battle, but about betraying my South Vietnamese comrades in arms, abandoning them to this fate. I was experiencing moral injury. Some members of ICE experienced moral injury when they were compelled by duty to separate children from their parents. Some doctors are experiencing moral injury because they have very high standards for saving lives, but they feel complicit in a system that is dysfunctional and is not protecting the lives of all patients equally and fairly. Some farmers, I would say, are experiencing moral injury because, try as hard as they may, they are losing at a business that is very much more than a business. It’s a precious way of life that has been in their families for generations. And they hold themselves personally responsible for losing the battle to sustain that way of life. I have cited populations where the rate of suicide is rising. Not just military veterans, but also police and correctional officers and doctors and small farmers are taking their own lives at increasing rates. I am not the only researcher who feels that moral injury is a primary engine of suicide.Post traumatic stress and moral injury are often co-present. I feel that mental health practitioners need to deal with the ramped up nervous system before much can be done about moral injury. Otherwise, it’s like trying to treat a patient with an active addiction. Once there is some evidence that a patient is gaining ground dealing with unconscious behaviors, then it becomes possible to deal with wounds to the conscience. Here’s where talk therapy comes in, and also — an under-represented line of inquiry in my opinion — the effectiveness of spiritual disciplines and religious rituals of forgiveness and personal transformation.

You may find the following books helpful:

On Chronic Stress and Its Long Term Damages to Health:

The Body Keeps the Score, by Bessel Van der Kolb
The Deepest Well, by Nadine Burke-Harris

On Moral Injury in Veterans, and Treating It:

The Things They Cannot Say, by Kevin Sites
Afterwar: Healing the Moral Wounds of Our Soldiers, by Nancy Sherman
Killing from the Inside Out, by Emmet Meagher and Jonathan Shay
Soul Repair, by Rita Nakashima Brock
On Killing, by Lt. Col. Grossman
Help for Moral Injury: Strategies and Interventions, by Cecilia Yocum

— TCDavis

A Good News Update from IVW

June 26, 2018 by Rx0puqi Leave a Comment

In August of 2015 I read the special issue of Quaker Journal about veteran suicide and was appalled. I asked several members of the Wilmington Friends Meeting to join me in seeing what we could do about that problem in Delaware, and several did. Their efforts led to the organization of the Interfaith Veterans’ Workgroup. Here’s the latest IVW update:

Lots happening!

We’re a 501C3! Thanks to IVW member, Rob Goldberg, who helped us file the legal papers, IVW is now a 501C3 organization. We have opened a bank account and our treasurer, Ted Garrison, is checking on a deadline for filing an annual required form for our non-taxable status.

IVW can now teleconference! Tom has acquired a Zoom account for his website business, so IVW will now be able to offer online access for meetings and webinars. The account can handle as many as 100 participants using either video or telephone connections. Although IVW is a Delaware organization, this technology gives IVW the ability to connect with colleagues far and wide who have similar interests and skills to share.

We’re growing at Facebook. IVW’s FaceBook group now has 101 members. See: https://www.facebook.com/groups/237928829966077. Most are local, but a few are out-of-staters interested in what we’re doing for and with veterans in the First State. You will find many helpful articles there about post traumatic stress, moral injury, and helping veterans use their warrior wisdom for peacemaking.

We’re getting fit and enjoying the outdoors. IVW member, Jack Sanders has led weekly hikes throughout the winter and spring, come rain or shine. Not only vets have participated, but also Tom’s wife, and Christian and Muslim friends from various congregations. A special thanks to Andre Dagenais, a leader in the Wilmington Trail Club, for frustrating Jack’s best efforts to get us lost. We’ve enjoyed hikes in White Clay Creek Preserve, Fair Hill Park, and Brandyine Park. Also a lovely kayaking afternoon on the Sassafras River, thanks to the hospitality of Jack’s brother.

We’re connecting to other trauma researchers. Tom has joined the steering committee of Trauma Matters Delaware, a coalition of therapists and other health professionals who are researching best practices for trauma treatment. Tom wears two hats on the committee, representing veterans and communities of faith. Tom has also joined the Veterans Suicide Prevention Committee which meets at the National Guard Headquarters monthly. They have asked him to lead a break-out group on moral injury at the Veterans’ Summit, to be held on September 11th.

We’re looking forward to using art. A member of Pacem in Terris, Dr. Robert Abel, will be working with IVW to organize a veterans’ art exhibit paralleling the youth art exhibit which Pacem has organized for the last two years. A teacher at the Wilmington Friends School has offered materials and space for working. Vets needn’t have any art experience to participate. We don’t expect this project to take shape until late August.

We’re using writing for healing. The IVW writers group is planning a meeting to be held at the Presbyterian Church of the Covenant. Another writers’ group is forming among returning citizens of New Beginnings-Next Step, a peer-led group that meets weekly at the Wilmington Friends Meeting House. Tom is exploring whether members of these two writers’ groups might want to meet together at least occasionally because they are both using writing for self-expression and healing, and some veterans and returning citizens share common challenges, such as dealing with anger, maintaining close relationships, and recovery from addiction.

We’re into meditation. An IVW member, Shannon Ayres, who teaches mindfulness meditation to elementary school children at Mount Pleasant School,has introduced Tom to Dr. Jenna Tedesco, who is training veterans to be teachers of mindfulness meditation. A class of eleven students will graduate soon and several will be looking for local teaching opportunities. This is a win-win: Veterans will help their communities and that work will give them a peacemaking purpose, a way to deal with a stressful and painful past. Dr. Tedesco’s class is considering using space at IVW’s headquarters, the Presbyterian Church of the Covenant, for their continuing education.

Why do IVW members hike? Why have we found meditation helpful in our own journey home from war? Why do we work through communities of faith? A scientific book about what stress does to children’s developing brains tells why. Tom highly recommends Dr. Nadine Burke-Harris’s book, The Deepest Well. At the end of it she writes that there are six activities that help people who have been repeatedly stressed to develop resiliency. They are: 1) get adequate sleep 2) get good nutrition 3) get regular exercise 4) meditate 5) receive mental health treatment when you need it, and 6) find a supportive community. IVW is working on several of these. You don’t have to be a counselor to help veterans come home and stay safe. If you have discovered for yourself the value of these basic healing activities, you can be part of a solution for increasing veterans’ resiliency. In fact, anyone’s. And that’s really good news!

Peace,

Tom