Tag Archives: Posttraumatic stress disorder

War-related moral injury: what is it? What helps? 


I’m reading David Wood’s What Have We Done: The Moral Injury of Our Longest Wars (2016, Little, Brown and Company). David is a journalist and has experiences embedded in military operations in Iraq and Afghanistan. PTSD is well-known and discussed, especially in the context of war. If you have listened to the news, you know that many veterans struggle with it and struggle with return to civilian life. Suicide rates of current and former military members should grab your attention and tell you that we have a serious problem on our hands. If you have read further, you probably have heard about treatments such as Prolonged Exposure and Cognitive Processing Therapy being used by VA mental health practitioners. 

This book, however, introduces readers to the concept of moral injury, a cousin to PTSD. While the features may look similar to PTSD, moral injury may better account for some of the experiences, especially where terror (the emotion, not behaviors) may not have been the main experience. 

The book opens with a story of a Nik, a Marine whose position came under fire from a small boy with an assault rifle. 

“According to the military’s exacting legal principles and rules, it was a justifiable kill, even laudable, an action taken against an enemy combatant in defense of Nik himself and his fellow marines. But now Nik is back home in civilian life, where killing a child violates the bedrock moral ideals we all hold. His action that day, righteous in combat, nonetheless is a bruise on his soul, a painful violation of the simple understanding of right and wrong that he and all of us carry subconsciously through life. 

… At home strangers thank him for his service, and politicians celebrate him and other combat veterans as heroes. And Nik carries on his conscience a child’s death.” (8)

The author goes on to argue with illustration after illustration that to go to war is to suffer moral injury, to suffer the disconnect between deeply held values and the experiences during war. While it is easy to see moral injury in the forced choice to kill a child vs. save one’s own life, moral injury can also result from being sent on a fool’s errand–political reasons sent to war vs. need to protect or defend freedoms. 

PTSD v. Moral Injury? 

Post-traumatic stress disorder is biology. It is the body’s involuntary physical reaction as we relive the intense fear of a life-threatening event and the scalding emotional responses that follow: terror and a debilitating sense of helplessness. (15)

He goes on for paragraphs to depict the experience of PTSD and its cascade of symptoms–“fear-circuitry dysregulation.” But then listen to how he talks about Nik

…Nik doesn’t have PTSD. What Nik struggles with is not the involuntary recurrence of fear. He’s okay with the crowds at Walmart. He doesn’t startle at loud noises. In contrast with veterans who’ve experienced PTSD, Nik didn’t feel the pain of his moral injury at the moment of the incident…. [But] he is bothered by the memory of that Afghan boy and with questions about what he did that day. Like all of us, Nik had always thought of himself as a good person. But does a good person kill a child? …No, a good person doesn’t kill a child, therefore I must be a bad person. …The symptoms can be similar to those of PTSD: anxiety, depression, sleeplessness, anger. But sorrow, remorse, grief, shame, bitterness, and moral confusion–what is right?–signal moral injury while flashbacks, loss of memory, fear, and startle complex seem to characterize PTSD. (17)

PTSD has little to do with sin. It is a psychological wound caused by something done to you. Someone with PTSD is a victim. A moral injury is a self-accusation, prompted by something you did, something you failed to do, as well as something done to you. (18)

Guilt and shame are key characteristics. Not being able to save a buddy, making a quick decision that also included losses of civilian life, betrayal by leaders but being forced to carry out orders, or not being protected by buddies–all can create a moral injury. Add a mega dose of grief/loss from death and loss of companionship after the unit breaks up and you have a serious problem. (Don’t forget once home and safe, the loss of adrenaline, the loss of status, the replacement of dullness and the rebuilding of old relationships without your friends and without purpose will enhance all painful feelings including nagging guilt and shame.)

Definition offered

The lasting psychological, biological, spiritual, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations. (250)

Spiritual community interventions? 

Despite their attractiveness, short-term interventions like CISD aren’t effective (chapter 6 details this). In addition, straight up attempts to challenge distorted thoughts are likely to fail. So, what might work? The book details some listening and validating activities by chaplains, including the burning of cards listing their “sins” as they leave the battlefront symbolizing their remorse and reception of God’s forgiveness. Talking about guilt, confessing failures and shame seem central. Note that confessing and validating do not necessarily mean that others agree that sins have been committed or that perceptions of self are accurate. They merely acknowledge the burden the veteran carries. Even the secular therapy models validate feelings of guilt while finding acceptance and forgiveness. Saying, “don’t blame yourself, you couldn’t help it” to Nik aren’t helpful. Finding a path that doesn’t blame or excuse (237) allows for a different path between all or nothing shame responses. 

It seems that what spiritual mentors and Christian practitioners have to offer in light of these themes are central to recovery from moral injury. 

The reality, says the author, our current therapies are only marginally helpful and sometimes harmful. Near the end of the book he concludes with this conviction,

True healing of veterans with war-related moral injuries will only come from community, however we and they define community–peers, neighborhoods, faith congregations, service organizations, individuals. That means it is up to us. (260)

And thus, YOU have a job to do

Listen. I highly recommend you read his last chapter (“Listen” begins on page 261). He will tell you how to engage a conversation in order to learn. No matter your personal beliefs about war, this is something you can do. Don’t look for the government to do the job, be the one to listen and learn yourself. Be the one to bear witness, as silently as you can. Your presence (more than your words) will convey compassion, understanding, and God’s presence.

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Filed under christian psychology, Good Books, Post-Traumatic Stress Disorder, trauma

Single session debriefing sessions? Helpful or harmful? 


I write this from Uganda having just completed a Community of Practice conference hosted by the Ugandan Bible Society. This community of practice is for bible-based trauma healing facilitators and local mental and public health experts. I presented on an update to PTSD causes, effects, and treatment. We looked at the value of Scripture engagement around the topics of trauma, loss, and recovery as well as how it fits into the larger picture of trauma counseling. 

Much of what we clinicians know and do for treatment for PTSD symptoms is based on partial research but a significant dose of “clinical judgment.” What is that? Well, it is treatment models that may have some empirical support but mostly formed over long-held assumptions in the field. One of those assumptions is that we may be able to prevent PTSD if we provide group or individual debriefing sessions soon after a traumatic experience. These debriefing sessions have been offered for decades to first responders, humanitarians, and missionaries after exposure to traumatic and tragic events. In recent years we have seen some evidence that some may not be helped but these sessions. In fact, some may even be harmed. 

The evidence of possible harm is not new. Yet, debriefing is still offered indiscriminately. We find it hard to let go what seems to work. Today I was able to read a 2006 study published in the British Journal of Psychiatry (citation below). This bit of research compared emotional debriefing, educational only debriefing, and no treatment. This study of Dutch civilians who had experienced a single episode of trauma within the last two weeks found that all three groups (emotion oriented debriefing, education only, and no treatment) saw a decrease of symptoms at 2 and 6 weeks post intervention. There was no benefit from either form of debriefing found in this study. 

In addition to no benefit, those individuals with high arounsal trauma symptoms who completed emotional debriefing showed higher rates of PTSD symptoms than the those with higher arousal who did nothing or only the educational oriented debriefing intervention. So, some forms of debriefing may actually worsen symptoms. Why? The authors surmise, 

In previous studies it has been established that high degrees of arousal in the immediate aftermath of a traumatic event are associated with an increased risk for the development of PTSD, measured both by self-report (Carlier et al, 1997; Schell et al, 2004) and physiologically by means of heart rate response (Shalev et al, 1998; Bryant et al, 2000; Zatzick et al, 2005). Encouraging highly aroused trauma survivors to express their feeling and emotions concerning the trauma might activate the sympathetic nervous system to such a degree that successful encoding of the traumatic memory is disrupted. Moreover, during an emotional debriefing session negative appraisal of one’s sense of mastery may be promoted (Weisaeth, 2000). This is assumed to keep the hyperreactive individual in a state of high arousal which may cause symptoms of PTSD to escalate rather than resolve (McCleery & Harvey, 2004). 

So, what should we do with this information? Nothing? No. But what we do should not harm, especially when we know some may be harmed. I suggest a few possible outcomes:

  1. Education about PTSD and trauma should continue. This study does not reveal harm for this intervention and given the relatively low trauma symptoms in this study (and the possibility some may have already been aware of what trauma is), education is likely to be helpful. Education is not only about trauma but also about good coping skills and activities. It does not focus on the events of the trauma experienced.
  2. Bible-based trauma healing begins not with a person’s story but looks at culture and common reactions. It normalizes pain and suffering and connects people to God and others. We do not yet have great empirical evidence (it is being collected) that such an intervention is helpful or harmful. But it appears that giving people permission to ask questions of their faith and to see that God encourages lament may still be helpful. 
  3. We need assessment of the growing movement and art oriented responses to trauma. What do these non-talk therapies add to the prevention or intervention strategies? 
  4. Debriefing or talking about a trauma that has just happened should focus less on replaying the details and more on current cognitive and affective impact with focus on resilience and boosting existing capacities. Brief assessment of arousal symptoms may well be warranted by those who promote processing trauma stories. This may be why NET, CPT and DBT oriented PE have lower drop-out rates than classic PE (prolonged exposure) therapy. 

Citation: Emotional or educational debriefing after psychological trauma (Randomised controlled trial) by MARIT SIJBRANDIJ, MIRANDA OLFF, JOHANNES B. REITSMA, INGRID V. E. CARLIER and BERTHOLD P. R. GERSONS. In BRITISH JOURNAL OF PSYCHIATRY (2006), 189, 150-155. doi: 10.1192/bjp.bp.105.021121

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Dissociating during trauma makes PTSD worse by increasing negative narratives about the self? Connecting recovery with rejecting these narratives


It is somewhat common for individuals to experiences a period of dissociation and/or perception of being frozen and unable to move during a traumatic experience. Dissociation is a catch-all word to describe experiences where a person is somehow disconnected from a portion of their senses making what is happening feel somehow unreal. Experiences can include emotional numbness, feeling events are not real, not feeling in one’s own body, or not remembering what just happened.

In the April issue of the Journal of Trauma Stress researchers discuss possible connections between experiencing dissociation during a trauma and increased negative beliefs about the self. Dissociation during a trauma is called “peri-traumatic dissociation.” It is already understood that peri-traumatic dissociation is a strong predictor of subsequent PTSD diagnosis. 

This short study suggests that those who have dissociative experiences during trauma may be more likely to think negatively about themselves, both about their trauma experiences (e.g., I should have been able to stop it) and their present feelings about themselves (e.g., I’m unreliable). The researchers suggest that therapists ask clients about both forms of negative views of self if the client describes dissociative like symptoms during the trauma experience. 

It would have been helpful if the researchers connected their work with that of shame experiences. We continue to try to understand why some people find some experiences more traumatizing and thus have greater difficulty finding recovery. It seems that shame is distinctly tied to chronic trauma and being stuck in negative self-talk narratives. It may be that those who struggle the most with negative self-talk (I should have been able to stop my abuser) experience the most shame. But I have yet to see anyone try to parse that out. 

In my experience, negative attributions about the self are just about the hardest things for us to change. We may have developed these well-formed beliefs from failure experiences or we may have had them formed for us by our families. But whatever the cause, they are so very hard to let go. In fact, when others show kindness to our perceived uglyness, we tend to pull back, refusing to allow these parts to be acceptable.

What is it about letting go of our shame and accepting ourselves as normal, as valuable?  How would you articulate the problem?
*Thompson-Hollands, J., Jun, J.J. & Sloan, D.M. (2017). The Association Between Peritraumatic Dissociation and PTSD Symptoms: The Mediating Role of Negative Beliefs About the Self. JTS, 30, 190-194.  

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Filed under Abuse, counseling, counseling science, Post-Traumatic Stress Disorder

Watch this on shame and trauma


A couple of years ago Diane Langberg spoke on shame and trauma for the American Bible Society. I highly recommend this 56 minute presentation. She talks about the experience of shame, the stickiness of self, communal forms of shame, and the myriad ways we respond to shame across various cultures.

We watched it again in staff meeting today. Make sure you catch her discussion of what some cultures believe cleanse shame. And then notice how that is close but a huge distortion from a Christian view of what heals shame.

Watch it here.

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Counseling Adult Survivors of Child Sexual Abuse: Phase 2 mis-steps and correctives


Today Dr. Diane Langberg and I will be offering a 3 hour pre-conference CE training at AACC’s 2015 World Conference here in Nashville, TN. Our focus is on some of the common counselor mistakes made during the phase of processing the abuse history and all that happens as a person tries to see self and history through different eyes. We focus on the relational approach to repair the mistakes we make. I have a small bit on reframing resilience and posttraumatic growth. Our perceptions of recovery and where we (counselors and clients) should be headed sometimes need to be examined.

For those interested in seeing the slides from my portion of the talk, click: AACC WC Pre-conf 2015

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How childhood trauma could be mistaken for ADHD


This article: (http://acestoohigh.com/2014/07/07/how-childhood-trauma-could-be-mistaken-for-adhd/) was sent to me by a GTRI student (Thanks Charity!). Worth the read to consider how we may mistake hyperactivity as evidence of ADHD vs. evidence of hypervigilance and PTSD. Given the high prevelance of ADHD diagnoses in areas where there is also much trauma (urban and impoverished settings), it stands to reason that there could be significant misdiagnoses. I began to understand this problem some 17 years ago during my pre and post doc experience in small town Concord, New Hampshire. We saw all sorts of boys first diagnosed with ADHD, then diagnosed (and heavily drugged) with bipolar disorder. Back then we called them emotionally-dysregulated. Nearly all had been subject to domestic violence and had witnessed their mothers abused by boyfriends. A large number had seen their mothers had guns held to their heads. Such experiences shape a child and so it stands to reason that a brain bathed in the hormones released during terror and horror would have an impact. It is also true that in this same population there was a high incidence of tobacco use, also known to be highly correlated with ADHD diagnosed children.

My suspicion is that one day we will find syndromes that encompass both diagnoses but that will not be until we have better understanding and technology to assess what is happening in the brain during an episode of “hyperactivity.”

Check out the above article and if you are a clinician, consider alternative explanations for ADHD diagnosed children. Do you see signs of emotion dysregulation? And if so, how might that be more central feature of the treatment plan?

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Brooks on journaling about emotions


Friend Jeff McMullen pointed out a recent David Brooks op ed in the New York Times. (Read it here). While I’m not sure I agree fully with his journaling/not journaling point he says something very important about the timing of writing one’s emotions after a traumatic event. He says,

When people examine themselves from too close, they often end up ruminating or oversimplifying. Rumination is like that middle-of-the-night thinking — when the rest of the world is hidden by darkness and the mind descends into a spiral of endless reaction to itself. People have repetitive thoughts, but don’t take action. Depressed ruminators end up making themselves more depressed.

Then later, this important distinction between immediate processing of emotions and later processing,

We are better self-perceivers if we can create distance and see the general contours of our emergent system selves — rather than trying to unpack constituent parts. This can be done in several ways.

First, you can distance yourself by time. A program called Critical Incident Stress Debriefing had victims of trauma write down their emotions right after the event. (The idea was they shouldn’t bottle up their feelings.) But people who did so suffered more post-traumatic stress and were more depressed in the ensuing weeks. Their intimate reflections impeded healing and froze the pain. But people who write about trauma later on can place a broader perspective on things. Their lives are improved by the exercise.

David points to some research that exists that suggest CISD is unhelpful for some participants. Some are made worse. Yet, narrating one’s trauma in the broader context of a life tend to see a reduction of symptoms. The difference seems to be whether the focus in on life or mostly on the trauma. Trauma in perspective is the goal. Just reviewing trauma may in fact strengthen the traumatic reaction rather than weaken it.

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GTRI 2014: Day 4


July 4. Transit day.

Today is a transit day. Breakfast of hardboiled egg, bread, and coffee. Talked with Klero of South Sudan. Discussed ideas of how to bring GTRI courses/materials and other counseling training to local areas here in Uganda and in S. Sudan. While Juba has great Internet per Klero, most people there do not have access to it. The same is true here in Uganda. I am very interested in finding a way to bring this training (videos, readings, exercises) to this region without it being in an online format as it is right now. Seems the areas of greatest interest are basic helping skills, trauma healing from the Bible Society, deeper understanding of impact of trauma and expression of PTSD across cultures, and exposure to psychopathology. My goal would be to give this material away and offer live conferencing sessions to the training mentor as needed. Then, possibly follow-up with a visit to “t0p-up” as Harriet Hill is fond of saying.

Anyone want to fund that or help me figure out how to get others to do so? (Smile)

After breakfast we made our way to a nearby Catholic college to talk with Sister Bokiambo and the dean of the counseling department, Fr Evarist Gabosya Ankwasiize. They were interested in future opportunities with shared learning (my bringing students here to engage and interact with their students and participate in joint training). I left with new ideas for this location (on the shorts of Victoria) and with the encouragement that the Bible Society might be able to begin some seminars here to improve the dialogue between Scripture engaged trauma care and traditional mental health trauma care.

After a lunch of fried fish on the shorts of Victoria, I said my good-byes to Justus and Esther at Entebbe airport. The added security was quite evident (3 bag checks and 3 metal detectors before boarding) but there were no problems. The flight to Kigali was under 1 hour on a very new Rwandair airplane. Just enough time for a Passion fruit drink from the steward. Arrived to significant upgrades to the airport.

Arrived at Solace Ministries Guesthouse, our usual haunts since 2011. Solace isn’t hotel level but I love it for many reasons: Simeon’s great cooking (he makes fantastic vegetable soups and dessert of fresh tropical fruit and ice cream tonight), my money goes to a ministry and not a behemoth corporation, the water is hot, the rooms are clean, and it is centrally located. Seems Internet is a bit upgraded since I was able to SKYPE with Kim and boys.  [For a 2012 video of Solace Guesthouse, see here.]

I arrived here after the major July 4 celebrations today. Today marks the end of the 100 day mourning period and celebrates the liberation of Kigali. This is the 20th anniversary. A number of fireworks were shot off tonight, which I was told later triggered some local people into thinking the city was under attack.

Tomorrow, Lord willing, the rest of the team will arrive from the US and other points and our GTRI immersion trip will begin in earnest.

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Training Trauma Healers For The Church


Over at our faculty blog site you can find my summary of a recent trauma recovery training for pastors and church leaders. Biblical co-sponsored this training with the American Bible Society in an attempt to bring a well-established, scripture-engaged trauma healing model to the Philadelphia area. Read more about the model and its value as well as see a picture of the training (thanks Heather Drew).

Trauma comes to us in all shapes and sizes. Traumatized outsiders (i.e., immigrants), child sexual abuse, domestic violence, community violence, racial injustice and natural disasters are here, not just something that is “over there.” While we may have more professional mental health resources here than other communities have access to, we still do not have enough to serve the need. And even if we did, the best models of recovery connected traumatized people to their faith and their communities. What better place to do that than in the church?

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Filed under Biblical Seminary, counseling, counseling skills, suffering, trauma

Can you have “church PTSD”?


A friend of mine has written about her experience as a pastor’s wife and youth worker. Having gone through several painful experiences–“normal” church drama and then way beyond normal–at the hands of other church leaders, she details her current “church PTSD” that kicks in now when considering going to church

What if I WANT the community and the bumping up against different people with different opinions, but I CAN’T, I mean physically CAN’T go?  I have usually discovered in life that if I have a feeling, I’m not the only one.  So it makes me think there must be others out there like me.

What do I mean by “physically unable”?  I shake, I cry uncontrollably, my skin crawls, I am unable to speak.  It’s pretty difficult to be a part of a community, broken or not, with all of that going on.

Honestly, I have something akin to a PTSD (not to take away from anyone who actually has full-blown PTSD) when it comes to church.  When I hear people talking in Christian catch phrases I want to run away.  This is the language of the culture of people who persecuted and bullied my family and me.  If you speak their language, you must be one of them, too.  So I stay away.

Having worked with a large number of current and former pastors and families, this reaction is sadly not unique. So, it begs the question: What might be the root of this “church PTSD” (by the way, I think some of these features sound just like PTSD so we may not need the quotes)?

My friend hits the nail on the head: we accept meanness in the church because we fear disrupting our own safety and security.

there is a culture of acceptance in the church today that allows for people to be treated terribly under the umbrella of it being what is “best for the church”.  I would imagine that if a teacher was abusing children in the toddler department or if there were drunken parties going on at youth group there would be some type of outrage, as there should be.  But somehow just plain being “mean” doesn’t garner any type of outrage.  “It’s not ideal, but we are fallen people, after all, so you can’t expect anything better.”

Read her full post over at Scot McKnight’s blog here. Consider what one thing you might do to stand up to those who put down others rather than image Christ in sacrificing for the weaker party.  

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Filed under Abuse, Christianity, Christianity: Leaders and Leadership, church and culture, conflicts, suffering, trauma