Understanding Post Traumatic Stress and Moral Injury

Recent interfaith tweets

About two years ago I founded the Interfaith Veterans’ Workgroup, to see what could be done to keep veterans from killing themselves. They were doing that at more than twenty a day. After two years of research I understand better the role of post traumatic stress and moral injury in veterans’ depression, and I’m coming to see that there are some non-clinical ways of helping warriors come home. Please read on:

Post Traumatic Stress is in the Body

A good book to understand the treatment of trauma is The Body Keeps the Score, by Bessel Van der Kolk.  PTSD affects the bottom and back of the brain.  That’s the primitive part that takes care of automatic functions, like breathing, the heart’s beating, etc.  Living under ongoing threat, as in a war zone, conditions that part of the brain to react aggressively without thinking.  PTS is in the entire body.  Warring creates muscle memory for self-preservation.  When warriors come home, and this can be done these days in a matter of hours, the muscle memory continues.  The whole body is still on combat alert.  One is hyper vigilant.  Sleep is difficult.  And when even a slight provocation occurs, like being cut off in traffic, the body reacts aggressively, automatically.  No thinking is involved.  The primitive brain is still doing its thing.  This condition can endure for many years.

Moral Injury is Felt After You’ve Had Time to Think

War is not heroic, as in the movies.  In war you do things merely to stay alive. You do them automatically, without thinking.  After a firefight you may not be proud of your conduct.  Maybe you killed a civilian who got in the way.  Maybe you failed to save a buddy.  Maybe out of anger you abused a prisoner, killed a prisoner, desecrated a corpse. Maybe in a strange moment you got in touch with the humanity of your enemy and you feel bad about shooting him down in an ambush instead of in the give and take of a fair firefight.  After you’ve had time to think there are so many ways to feel rotten about yourself for doing what you did, or failing to do what you think you should have done.  Such nagging reflections happen in the top and front of the brain, the pre-frontal lobes. PTS and moral injury are often co-present.  Both contribute to depression, but I think moral injury is probably the stronger factor in veteran suicide.

Returning Veterans and Returning Citizens from Prison Face Some Similar Challenges

Here’s a piece I shared with IVW and some friends who are working with men and women returning from prison:
For about two years I have been leading a group devoted to helping combat veterans transition successfully to civilian life (the Interfaith Veterans Workgroup).  Concurrently I have been sitting weekly with New Beginnings-Next Step, which helps former inmates transition from prison to society.  I have noticed that some veterans and many returning citizens from prison face similar emotional and behavioral challenges: managing anger, maintaining close relationships, and dealing with depression without self-medicating with substances that often lead to addiction.
One could say that these similarities stem from habits formed for self-protection in persons who have had to cope for a rather long time in dangerous and violent circumstances.  The CDC study done in Wilmington indicates that most young men who end up in prison for gun crimes experienced trauma as children. They were desensitized to violence not only by what they saw on TV or in video games, but much more so by witnessing maimings and killings where they lived, and sometimes in their own families.  Furthermore, they resorted to guns not only as a means of self-protection, but also as a means to assert themselves, to gain and keep respect; and in the long run respect “in the hood” is needed for survival, or so I’m told.  Thus, a habit of responding quickly and violently to even apparent challenges to the self becomes ingrained in the nervous system. Violent aggression becomes a habit of the body.  One doesn’t think anymore before pulling the trigger.
Lieutenant Davis driving boat in Vietnam

author, driving the “skimmer” in Mekong Delta, 1970

In 1970 I had accompanied South Vietnamese sailors to a village in enemy territory where we distributed medicines to “win hearts and minds.”  On the way back to our base we were ambushed.  We couldn’t see who was shooting at us, but every man in our boat sprayed the dense rushes on the canal bank immediately, without thinking.  Our rapid violent response suppressed enemy fire and got us out of that tight spot.  Our military training had desensitized us to killing and had ingrained in our very bodies an automatic response.  In an ambush there is no time to think.  One shoots to survive, and if one does survive, then one has the time afterwards to sort out what one did.  When there was no target, as in this case, one may wonder whether anyone got hit, and if so, was it a shooter or an innocent bystander?

 I know from personal experience that a habit of violent aggression gets ingrained in persons who have had to cope with living under constant threat.  That habit can be unlearned, but it takes time and dedication. Up to now our military hasn’t recognized a need to de-program warriors. You fly out of a war zone and presto, you’re back in the civilized world.  But your body is still on combat alert. Anger, may I suggest, is a natural self-protective human response. In a war zone it can indeed preserve your life.  But when you try to transition to civilization, what saved your life in war is likely to destroy it back home. Your body, not just your mind but your body too, needs to develop new habits for dealing with perceived challenges to the self.
That’s where mind-body disciplines like the martial arts, yoga, and mindfulness based stress reduction come in, and also the Alternative to Violence Project invented by Quakers.  The military deliberately trains people to not be anguished by killing, and to react immediately and violently to a perceived attack.  Those habits of the mind and body are needed in a theater of war, but they must be unlearned upon return, else former warriors may harm others or themselves.

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