Achilles in Viet Nam

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Resources on Moral Injury in Returning Vets Rev. Stephen Muse, Phd

Moral injury, according to Jonathan Shay, MD, PhD who first introduced this term into modern context in his ground-breaking book Achilles in Viet Nam, described it as a “violation of what’s right” – something that is a central theme to Homer’s Iliad which portrays the undoing of character of Achilles and his recovery. Recent literature and research have broadened and refined the definition. VA Doctors working with veterans have defined moral injury as: “perpetrating, failing to prevent, bearing witness to or learning about acts that transgress deeply held moral beliefs and expectations”.


Soul Repair: Recovering From Moral Injury After War

Rita Nakashima Brock and Gabriella Lettini

Beacon Press, 2012

A small important contribution to the dialogue on moral injury that clearly distinguishes the relationship between PTSD and the spiritual soul pain that can accompany it and also remain without it. It is a testimony to why those who hear other’s pain need to be familiar with both the symptoms and causes of post traumatic stress and the deeper soul pain of the spiritual question that is at the heart of the wound.

The Moral Warrior: Ethics and Service in the U.S. Military (Suny Series, Ethics and the Military Profession)

Martin L. Cook

SUNY Press: New York

Explores moral issues pervading the geopolitical landscape of military service in the current “new world order” in which the United States has unparalleled military presence and power. What is the purpose of the military in this context and what is moral about how it is used? Addresses questions in light of the moral challenges posed by the "war" on terrorism.
War and Redemption: Treatment and Recovery In Combat-related Traumatic Stress Disorder

Dr. Larry Dewey

Ashgate Publishers Ltd:Great Britain, 2004

Dr. Dewey is Chief of Psychiatry at Boise, Idaho VA Medical Center and Associate Clinical Professor of Psychiatry at the University of Washington School of Medicine. He has extensive experience working with combat veterans and their families. Points to the power of listening, understanding and forgiveness in redeeming seemingly unredeemable experiences. Offers many stories of veterans who learned to deal with their PTSD and understand what is happening to them. Helps family members who love them understand and find a way to support them.
On Killing: The Psychological Cost of Learning to Kill in War and Society.

Lt. Col Dave Grossman,

New York: Back Bay Books. 1996

The best and most scientifically researched book on the psychology of killing. Includes many first hand accounts of soldiers, police, etc. Grossman identifies how the military changed their training tactics in order to overcome the innate biological resistance to killing another human being in response to studies showing how the majority of soldiers in WWII refused to shoot at other human beings. He reflects on the rise of violence within American culture and the impact of violent video games that parallel some of the military training of soldiers, but without having a command structure in place for the young people who are using them, they are missing an important safety catch to prevent random violence.

On Combat: The Psychology and Physiology of Deadly Conflict in War and in Peace. Grossman, D., & Christensen, L.

Millstadt, IL: PPCT Research Publications, 2004

Draws on many first hand experiences and research to explore what happens to the human body under the stresses of combat and how warriors inoculate themselves against breaking down under the stress of a fight. He looks at the history and evolution of the psychology of combat; what allows persons to kill others and what can this tell us about the rise of domestic violence in America. Attention is given to the Judeo-Christian view of killing in combat and the notion of the just war, arguing for the crucial difference between communally sanctioned killing under orders for the sake of justice and killing out of vengeance on one’s own.
Trauma and Recovery: The Aftermath of Violence From Domestic Abuse to Political Terror

Judith Herman,

New York: Basic Books, 1997

A now classic work on PTSD and the psychological effects of trauma. One of the first to recognize the moral importance of communal recognition of a problem in order to address it. Comprehensive and prophetic.

Once A Warrior Always a Warrior: Navigating the Transition from Combat to Home—Including Combat Stress, PTSD and mTBI

Charles W. Hoge, MD Colonel, U.S. Army (Ret.)

GPP life, Guilford: Connecticut, 2010

This is a practical handbook for veterans returning from war. It is without unnecessary jargon and helpful both to vets as well as lay civilians who want to understand how preparing for and serving in combat conditions trains the nervous system to acclimatize to battlemind for the sake of survival. Learning to recognize the signs of this and shifting frames of reference as well as intentional ways to accommodate combat learning to life at home in the civilian world is set forth in a step by step manner. The author directed the U.S. military’s premier research program in the neurophysiological effects of combat from 2002-2009 at Walter Reed Army Institute Research.

The Handbook on Best Practices for the Provision of Spiritual Care to. Persons with Post Traumatic Stress. Disorder and Traumatic. Brain Injury. Hughes, B and Handzo, G. U.S. Government public document. 107pp. Comprehensive overview of PTSD and TBI and treatments to date, including spiritual-based treatments from a variety of religious traditions. Also includes excellent bibliography of related articles
Perpetration-Induced Traumatic Stress: The Psychological Consequences of Killing.

Rachel MacNair

New York: Authors Choice Press, 2005

Perpetration-Induced traumatic Stress (PITSA) is a type of PTSD that results not from being the victim of a trauma, but form having been actively involved in acts of socially acceptable or mandated perpetration, in the line of duty such as a soldier, policeman, executioner, etc. MacNair suggests that the consequences of perpetrated acts of violence leads to greater severity and different symptoms related to those of moral injury.

We Were Soldiers Once and Young

Lt. Gen. H.G. Moore and Joseph L. Galloway

Presidio Press (Random House):New York, 1992

A vivid and honest look at the intense conditions of modern warfare and the impact of combat on soldiers as well as the bonds that are created between through this process.

What It is Like to Go to War, Karl Marlantes, Atlantic Monthly Press: New York, 2011 (from review) “recounts experiences that, outside the arena of war, are horrifying or embarrassing and addresses a soldier’s self-imposed “code of silence” as an attempt to fit back in to a society that “simply wants us to shut up about all of this.” While American pop culture celebrates the warrior spirit and winning the battle, “reconciling the moral conduct we are taught…with the brutal acts we do in war has been a problem for warriors of good conscience for centuries.” Marlantes tempers the brutal truths of fear, power games, and courage with a thoughtful prescription for our soldiers’ well-being; caring for our soldiers and their families differently will benefit society as a whole.”
We Are Soldiers Still

Lt. Gen. H.G. Moore and Joseph L. Galloway

Harper Perennial: New York, 2008

A sequel to their first book, this volume is the story of redemption, forgiveness and respect between former enemies who meet each other decades later. It is a testimony to the power of human encounter where friendship can heal the wounds of war. “This book proves again that Moore is an exceptionally thoughtful, compassionate and courageous leader (he was one of a handful of army officers who studied the history of the Vietnam wars before he arrived) and a strong voice for reconciliation and for honoring the men with whom he served.” From Publishers Weekly
Achilles in Viet Nam: Combat Trauma and the Undoing of Character

Jonathan Shay, MD, PhD

Simon & Schuster: New York, 1995

The concept of moral injury as a “betrayal of what’s right” by the command structure, was first proposed by Shay in this book. Interestingly he finds the antecedents and observation of this in the 300 year old epic of Homer who first identified this in the Trojan war. Shay, a physician with a PhD in classics, identifies this betrayal as the primary catalyst in what he calls the “undoing of character.” Weaving modern day interviews with veterans of the Viet Nam war with insights from observations of The Illiad, Shay reveals the power of betrayal and dishonor in the veteran’s life that leads to rage at the injustice, withdrawal, mistrust and increased vulnerability to what he calls the ‘berserker state’ and the destruction of character. Shay is an advocate for policy changes that acknowledge and permit grief work as a means to preserving conscience that is necessary for the preservation of character.
Odysseus in America: Combat Trauma and the Trials of Homecoming

Jonathan Shay, MD, PhD

Charles Scribner: New York, 2003

In this sequel to his first volume, Shay continues to detailed discussion of the warrior’s experience of returning home, examined through the lens of Odysseus, the second volume in Homer’s war epic. Using stories of Viet Nam veterans he has worked with, he illuminates the obstacles encountered by the combat veteran seeking to return home. Shay argues for the importance of communal cohesion as a means of preserving the character of soldiers who fight together and should be allowed to grieve together.

The Untold War: Inside the Hearts, Minds, and Souls of Our Soldiers

Sherman, N.

W.W. Norton & Company: New York, 2010

A philosopher and psychoanalyst explores the inner conflictual world of combat veterans. As she explains: “Every person’s experience is unique. Therefore philosophy, with its thousands of years of nuanced discussion, is better suited to address moral conflicts than psychology. It is philosophy’s very complexity that can be so healing.”
Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery Tanielian, T.L., & Jaycox, L.H. (Eds.). (2008). . Santa Monica, CA: RAND Corporation. Describes the post-deployment health needs associated with major depression, traumatic brain injury, and PTSD among returning OEF and IEF Service members.
War and the Soul: Healing Our Nation's Veterans from Post-Traumatic Stress Disorder 

Edward Tick, PhD.

Quest Books: Wheaton, Ill, 2005

Tick, originally a conscientious objector to the Viet Nam War, became a therapist whose work was devoted to returning veterans from that war, specifically their “soul wounds.” His encounters changed his view of life and of himself. He focuses on the power of forgiveness obtained through the hard work of facing one’s former enemy – both internally and in reality. He accompanied a number of his clients back to Viet Nam where they literally faced the places that had changed since they were there. Veterans who have made this journey have a great deal to offer society based on their experiences and the wisdom they have garnered through them.

ARTICLES Adaptive Disclosure Therapy: A Combat Specific PTSD Treatment, Litz, BT, Steenkamp, M. Oct 2012 Abstract: More than 2 million U.S. troops have served in the wars in Afghanistan and Iraq. Finding from epidemiologic stuidies of infantry troops in the early stages of the wars suggest that 10-18% of combat troops experience deployment-related psychological health problems, such as posttraumatic stress disorder (PTSD). Once service members and new Veterans develop sustained mental health problems related to combat and operational stress, many are at risk to remain chronic across the lifespan. Thus, primary and secondary prevention of PTSD is a critical challenge for the military and the VA. We have developed a novel intervention. Adaptive Disclosure (AD) to address these needs. AD is a hybrid and extension of evidence-informed cognitive-behavioral therapy strategies packages and sequenced to target the three high base-rate combat and operational traumas, namely life-threat trauma, loss (principally traumatic loss) and experiences that produce inner moral conflict. AD employs a Prolonged Exposure (PE) strategy (imaginal emotional processing of an event) and cognitive-therapy-based techniques used in Cognitive Processing Therpay (CPT), but also includes gestalt-therpay techniques designed to target loss and moral injury. In our open pilot trial, we demonstrated treatment acceptability among Marines and large reductions in PTSD and comorbid symptoms. The primary objective of the current randomized control noninferiority trial is to determine ahether AD is at least as effective as CPT, cognitive only version (CPT-C) in terms of its impact on deployment-related psychological health problems (specificially PTSD and depression) and functioning. As secondary aims, we have specified some comparison in which we believe that AD will be superior to CPT-C (degree of change in posttraumatic grief, moral injury, resiliences, and post traumatic growth, as well as degree of treatment acceptability) and we propose to evaluate a posited mechanism of change (trauma-related option)., Currier, JM, Holland, JM, Drescher, K, Foy, D., “Initial Psychometic Evaluation of the Moral Injury Questionnaire-Military Version Clinical Psychology Psychotherapy. 2013 Sep 10 Abstract: Moral injury is an emerging construct related to negative consequences associated with war-zone stressors that transgress military veterans' deeply held values/beliefs. Given the newness of the construct, there is a need for instrumentation that might assess morally injurious experiences (MIEs) in this population. Drawing on a community sample of 131 Iraq and/or Afghanistan Veterans and clinical sample of 82 returning Veterans, we conducted an initial psychometric evaluation of the newly developed Moral Injury Questionnaire-Military version (MIQ-M)-a 20-item self-report measure for assessing MIEs. Possibly due to low rates of reporting, an item assessing sexual trauma did not yield favorable psychometric properties and was excluded from analyses. Veterans in the clinical sample endorsed significantly higher scores across MIQ-M items. Factor analytic results for the final 19 items supported a unidimensional structure, and convergent validity analyses revealed that higher scores (indicative of more MIEs) were correlated with greater general combat exposure, impairments in work/social functioning, posttraumatic stress and depression in the community sample. In addition, when controlling for demographics, deployment-related factors and exposure to life threat stressors associated with combat, tests of incremental validity indicated that MIQ-M scores were also uniquely linked with suicide risk and other mental health outcomes. These findings provide preliminary evidence for the validity of the MIQ-M and support the applicability of this measure for further research and clinical work with Veterans. Copyright © 2013 John Wiley & Sons, Ltd. Nash, WP, Marino, Carper, TL, Mills, MA, Au T, Goldsmith, A, Litz, BT. “Psychometric Evaluation of the Moral Injury Events Scale. Military Medicine, 2013 Jun:178(6) 646-652, Abstract:Literature describing the phenomenology of the stress of combat suggests that war-zone experiences may lead to adverse psychological outcomes such as post-traumatic stress disorder not only because they expose persons to life threat and loss but also because they may contradict deeply held moral and ethical beliefs and expectations. We sought to develop and validate a measure of potentially morally injurious events as a necessary step toward studying moral injury as a possible adverse consequence of combat. We administered an 11-item, self-report Moral Injury Events Scale to active duty Marines 1 week and 3 months following war-zone deployment. Two items were eliminated because of low item-total correlations. The remaining 9 items were subjected to an exploratory factor analysis, which revealed two latent factors that we labeled perceived transgressions and perceived betrayals; these were confirmed via confirmatory factor analysis on an independent sample. The overall Moral Injury Events Scale and its two subscales had favorable internal validity, and comparisons between the 1-week and 3-month data suggested good temporal stability. Initial discriminant and concurrent validity were also established. Future research directions were discussed. Reprint & Copyright © 2013 Association of Military Surgeons of the U.S. A set of guidelines created by Care For the Troops initiative in Georgia, on how to establish Veteran Friendly Congregations. This PDF includes a detailed list of initiatives that can be customized and undertaken in the local parish as well as identifies the structure of volunteers needed to bring it off. Lists of possible workshops, how to put together care packages for deployed troops, ways to identify and welcome existing and returning members of the congregation who are veterans; and sample letters for returning veterans from the church, are included. Vol 33 of Journal of Reflective Practice: Formation and Supervision in Ministry is devoted to a symposium on Moral Injury. Free copies of on-line PDF’s of articles are available for down-load from leading authors in the field. David Wood “A Warrior’s Moral Dilemma” A three part series from investigative reporte who spent 35 year embedded with troops covering various wars and conflicts. “Post Traumatic Spiritual Alienation and Recovery in Vietnam Combat Veterans,” Brende, J. and McDonald, E. Spirituality Today, Winter 1989 Vol 41(3) 319-340. One of the first treatment protocols rooted in a spiritual approach to address moral injury, shame and guilt of combat veterans that trapped them in alienation from society, seeing themselves as conscienceless and having lost the faith they had prior to their war experiences. The article discusses Brende’s communal approach to working with the 12steps adapted to treatment of PTSD. Cf. for Brende’s 12 Step Workbook “Coping With the Aftermath of War.” A useful bibliography A paper developed by the Disciples of Christ which aims at allowing the Church to engage in reflection, prayer, research, and education around the concept of moral injury in veterans Litz BT, Stein N, Delaney E, Lebowitz L, Nash WP, Silva C, Maguen S. Clin Psychol Rev. 2009 Dec;29(8):695-706. Epub 2009 Jul 29. “Moral injury and moral repair in war veterans: a preliminary model and intervention strategy.” Abstract Throughout history, warriors have been confronted with moral and ethical challenges and modern unconventional and guerilla wars amplify these challenges. Potentially morally injurious events, such as perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long-term, emotionally, psychologically, behaviorally, spiritually, and socially (what we label as moral injury). Although there has been some research on the consequences of unnecessary acts of violence in war zones, the lasting impact of morally injurious experience in war remains chiefly unaddressed. To stimulate a critical examination of moral injury, we review the available literature, define terms, and offer a working conceptual framework and a set of intervention strategies designed to repair moral injury. (PubMed - indexed for MEDLINE]

Brock, R.N., Miller, DB “Just War Theory: Are We Protecting the Moral Conscience of Soldiers?” Huffington Post, 10/14/2010 Huffington Post Article discusses the link between the military’s teaching that soldiers must keep a moral compass in war, yet denying the validity of conscientious objection to the moral grounds of a particular war as being unjust. CO status must be objection to all war as unjust, thus leading to Catch 22 of “If I fight in a war I consider unjust, I am immoral, if I don’t fight I go to jail.” Link to download the Truth Commission on Conscience in War. Report is the result of a national coalition of 60 religious, veterans, academic and advocacy groups advocating for greater religious freedom and protection of moral conscience in the military “Beyond PTSD: The Moral Casualties of War,” Camillo “Mac” Bica, June 8, 2007. Author is a former Marine from the Viet Nam War, founder of Veterans Self-Help Initiative and now professor of philosophy with a focus on Ethics. Article considers the nature of moral injury as revealed though several wars. Examines how it has been overlooked in therapy, rationalized away by chaplains and the damage done by this to soldiers who bear the weight. “The Impact of Reported Direct and Indirect Killing on Mental Health Symptoms in Iraq War Veterans” Maguen,S, Lucenko, BA, Reger, MA and Gahm, GA, Litz, BT, Seal, KH, Knight, SJ, and Marmar, CR Journal of Traumatic Stress, Vol. 23, No. 1, February 2010, pp. 86–90 Abstract This study examined the mental health impact of reported direct and indirect killing among 2,797 U.S. soldiers returning from Operation Iraqi Freedom. Data were collected as part of a postdeployment screening program at a large Army medical facility. Overall, 40% of soldiers reported killing or being responsible for killing during their deployment. Even after controlling for combat exposure, killing was a significant predictor of posttraumatic disorder (PTSD) symptoms, alcohol abuse, anger, and relationship problems. Military personnel returning from modern deployments are at risk of adverse mental health conditions and related psychosocial functioning related to killing in war. Mental health assessment and treatment should address reactions to killing to optimize readjustment following deployment. Fontana, A., & Rosenheck, R. (2004). “Trauma, change in strength of religious faith, and mental health service use among veterans treated for PTSD.” Journal of Nervous and Mental Disease, 192, 579–584. Examines the link between killing in combat and suffering moral injury as a result among out-patient and inpatient sample of Viet Nam combat Veterans. Results suggest that Veterans’ motivation to pursue therapy is “driven more by their guilt and the weakening of their religious faith than by the severity of their PTSD, symptoms or deficits in their social functioning.” The search for meaning and purpose to traumatic experiences raise the question of the importance of pastoral care and counseling for vets.

Beyond PTSD: Soldiers Have Injured Souls, by Diane Silver in Excellent article summarizing contributions of major theorists to date in the area of moral injury in Vets and offers brief historical chronicle of how it came to be on the forefront of current discussions.

Caring Connections: An Inter-Lutheran Journal for Practitioners and Teachers of Pastoral Care and Counseling. Vol 10, No. 1 2013. The issue is devoted to Hope, Resilience and Moral Injury in Combat Veterans and contains many useful articles.
S. Muse, “No Dead Man’s PrayerTouchstone Magazine. March/April 2013, pp 25-27

A look at the suffering of moral injury in combat veteran confronting his pain through the paradox of Psalm 88 in the context of pastoral counseling relationship.

WEBSITES Information on how to qualify as a Veteran Friendly Congregation and develop congregation-based Military Ministry programs.. videos, resources and information related to exploration of war and conscience, moral injury, conscientious objection, just war theory. Has a number of archived articles of relevance and “The Truth Commission Report” releases in 2010 Edward Tick’s website. He is author of War and the Soul and has drawn on lessons from traditional warrior about ritual and healing in his work with vets. He uses of ritual, trips to the battlefield and charity projects as part of the healing process. “Our goal is to alleviate the symptoms of PTSD by developing a new and honorable warrior identity through storytelling, purification, community forgiveness and healing, and restitution as outlined in Edward Tick's War and the Soul. In addition, we promote, train, and guide military, professional and community-based efforts to heal the effects of war.”


Veterans Administration Caregiver Support Hotline 1-855-260-3274 was created to recognize contributions made by caregivers allowing Veterans to remain at home surrounded by family and friends.  Monday-Friday 8AM to 11PM, Saturday 10:30AM to 6PM EST. Licensed clinical social workers are available to answer questions, listen to your concerns and directly link you to the Caregiver Support Coordinator at your local VA Medical Center. 
VA Caregiver Website US Dept. of Veterans Affairs sponsored website is a source for a variety of services designed specifically to support family members and caregivers of veterans as well as offering a listing of services and benefits for Veterans. A wealth of information and access to persons who can answer specific questions concerning resources.

VIDEO and PODCASTS Dr. Jonathan Shay offers a keynote address on the Combat Trauma and the Trials of Homecoming which focuses on the wide gap that can dived and swallow veterans and their families when they arrive home because of their vastly different experiences and expectations. He begins by saying that anyone who would listen to a returning veteran, “must learn how to go naked to show your humanity and to react with humanity to the pain and the fury of the veteran before you they will ever begin to trust you.” He suggests that we need a homecoming ritual of purification that is communal which civilians participate in as being an integral part. PBS presentation on the moral wounds of war A video interview with Nancy Sherman, philosopher, ethicist and psychoanalyst, discussing “moral residue and emotions” of soldiers related to their experiences. Author of The Untold War: Inside the Hearts, Minds, and Souls of Our Soldiers. “Soldiers carry all the moral weight of war, and we carry very little, and we need to share that moral burden by realizing that they are our surrogates” “It’s our job as civilians to tend to the returning warriors by bringing them into the center of the community,” says this psychotherapist and author of “War and the Soul.” Tick appreciates the spirituality of warrior culture and the ‘path’ of military service as a lifelong way of life that is a social contract with the rest of culture. He is very good on the complimentary and reciprocal nature of caring between warriors and the larger culture that contributes to the healing and growth of both groups. The veterans must tell their stories and we need to hear them, to witness them and to feel the pain and carry the responsibility of the stories together. Jonathan Shay, MD, PhD Short interview offering his original definition of moral injury (as “betrayal of what’s right”) in the context of war and how this changes the character of persons. CRG Director Martin Davis and Dr. Stephen Muse of the Pastoral Institute discuss moral injury in returning veterans and how congregations might best respond. We need to learn how to “listen, witness and weep” with and for veterans and all persons who have gone through major traumas. Dr. Stephen Muse speaks at St. Vladimir’s Seminary Education Day on the relationship between conscience and moral injury in returning vets and the relationship between the church and returning vets, who have a great deal to offer each other if both are willing to engage each other deeply. CBS interview with friends and family of Marine veteran Clay Hunt, a charismatic, handsome, intelligent combat veteran who had found new ways to serve others in disaster relief since his departure from the military. He suffered from PTSD, depression and deep moral injury to conscience he could not shake. He committed suicide by gunshot.

RELATED RESOURCES CONGREGATIONS SHOULD BE FAMILIAR WITH Vet to Vet Program is a volunteer organization for vets, staffed by vets who understand the ins and outs of the VA medical system and are both a resources as well as provide peer-to-peer counseling groups.

The Soul Repair Project,

Rita Nakashima Brock, Co-Director, Herman Keizer, Jr., Co-Director, Gabriella Lettini, Chair, National Board of Advisors. The Soul Repair Center’s stated goals are to:

  • conduct research, hold conferences, train educators, and create educational resources on moral injury and methods and strategies for healing it;

  • serve as a pilot for creating an additional five such centers over a period of five years;

  • train seminarians, clergy, mental health professionals, religious leaders, chaplains, and members of congregations and community organizations in healing moral injury; and

  • create robust, effective means of making such resources accessible and available online to religious and nonprofit organizations working with veterans.

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