post traumatic stress

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.

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