Q: One issue that veterans may face is moral injury. Can you talk about that?
A: Moral injury is a term that was first used after Vietnam. Moral injury is not a psychiatric diagnosis. It is feelings of shame and guilt that can be very corrosive and can lead to suicide. It overlaps with PTSD. You feel either you’ve let yourself down, or the government has let you down. And this can be very corrosive. Another thing that could happen is, say, you switched your tour of duty with a buddy, and he got killed and you didn’t. A very common scenario is you’re manning a checkpoint, and a car comes at you and doesn’t stop like it’s supposed to. You do what you’ve been trained to do, which is open fire, and check on the car afterward. And there’s four little kids and their parents in the car all dead. And that is something that even though that was your sort of duty, that it still eats at you because you have kids the same age as the ones who were dead in the car.
You can still have these feelings of shame and guilt, and it will often bleed into your relationships with your family. And that can lead to distance and divorce, which is a further risk factor for suicide.
Q: Are there are any specific treatments that have been designed for moral injury, different from PTSD or other conditions?
A: The Armed Services has set up a number of intensive programs at different places, and each is a little bit different. They usually integrate moral injury in with some of the other treatments. There was one at Fort Bliss, Tex., that had reiki; they had art therapy. And they had the chaplains working on moral injury. So there’s no medical treatment for it, but there certainly is talking about it, and for some people to go to a chaplain can be very helpful.
There’s a Military Health System Centers of Excellence, which is a place by the new Walter Reed on the campus, they have a marvelous wall full of masks. And the masks have been painted by soldiers with usually a combination of PTSD, TBI, and although it’s not an official psychiatric diagnosis, moral injury. They’re able to draw and paint. Another thing that’s been used quite a bit as writing therapy, and journaling, and just writing down how you feel about something, because you can do that without retraumatizing anybody else, except perhaps if you are working with a therapist.
Q: For therapists who are treating soldiers, veterans, are there specific challenges that they should be aware of? Are these patients maybe different from the patients that they might otherwise see? Are there specific pieces of advice as to how to engage them?
A: There are a few things that are different. One is that many people in the military are not used to talking about their feelings. And that’s especially if you’ve got a young man who only grunts and says: “Hooah!” That is going to be hard to break through. And that’s why some of these other ways of reaching somebody is very effective. Also, the military likes to have physical activity; they’re usually not comfortable sitting in a chair. If you’re a civilian psychiatrist, I don’t expect you to go bungee jumping with your patients. But what I’d recommend is that you recommend to your patients that they stay active.
Another thing about veterans is that they like to be self-sufficient. They really don’t like to ask for help, although they might ask for help for their buddy. After the Pentagon and 9/11, when I was working with senior officers, they never needed any help. No, but their buddy over here might, so I could help them in the guise of providing care for their buddy in a group setting. We could work with everybody and enhance cohesion, morale, bonding, “we’re all in this together” type of feeling.
I think one thing that’s really improved is that there is less stigma around PTSD. People are more willing to present for help, and some people have called PTSD the Purple Heart of mental disorders. People don’t feel like it’s as bad as having depression or anxiety. Even though PTSD often has depression and anxiety components to it – they run hand in hand – still, it’s sort of more honorable if you’ve been at war and have gotten PTSD.
Q: How have you been faring yourself, in the face of the 9/11 anniversary and recent events in Afghanistan?
A: (The Sept. 11 weekend) was very sad for me – and a lot of my colleagues [with] the combination of the 20th anniversary of 9/11, and the recent development. Fortunately, I have friends and people I can talk to. I walked with a colleague of mine who was in the Army. I’m following my own rule of the three buckets, so we took a walk around the hospital center for about 45 minutes, and we have five fish ponds here. And we went and looked at the fish, and talked to the fish. At the National Rehab Hospital, they were playing the guitar. So there’s are a variety of things that people can do.