Bruce Dow, M.D.

Moral Injury and PTSD

A recent article by Pauline Jelinek, Associated Press,  draws attention to “moral injury” from warfare.  My own experience working with Vietnam War veterans in San Diego supports many of Ms. Jelinek’s observations and conclusions.  I became a PTSD specialist at the San Diego VA Medical Center and the University of California, San Diego (UCSD), in the early 1990’s, during the first Gulf War, which triggered many Vietnam veterans.  After several years as an academic psychiatrist, helping set up PTSD programs at the VA hospital, I left the university setting and started a private practice in the community.  The VA sent me some of their most troubled patients with PTSD for more intensive treatment than was available in the hospital clinics.  Over the next 13 years I got to know five of these veterans quite well.  Our work together is highlighted in my book in preparation, TAKE CONTROL OF YOUR DREAMS: The Proven System for Ending Nightmares and Recovering from PTSD.  In addition to having PTSD from being in life-threatening combat situations, each veteran suffered from “moral injury”.  That is, they had nightmares and flashbacks about things they had done (or not done), as well as things that had been done to them or their buddies.

Moral injuries in military combatants are more complex than what we normally think of as PTSD.  Guilt and shame may be more prominent in such injuries than fear and anger.  One of my veterans described himself as a serial killer.  Another felt remorse over his ongoing homicidal impulses when angered; he had killed many enemy soldiers in combat.  Both veterans had been highly decorated and honored as war heroes.  Two other veterans felt remorse over situations in which they had killed women and/or children.  One veteran had nightmares about harsh interrogations he had witnessed or participated in.

Our discussions about these matters were mostly “off the record”.  I felt the need to protect each client’s privacy, while helping them manage their feelings of guilt and remorse; my official notes about their therapy had to be submitted to the VA as part of their records, available for authorized VA staff to see.  I also felt some concern about my complicity in their actions.  By helping them recover from behaviors they considered shameful, was I implicating myself?  By listening without expressing moral outrage, was I condoning what they had done?

Several years ago, in July, 2011, at a meeting on Complexities and Challenges of PTSD and TBI, held in Boston, and sponsored by Massachusetts General Hospital’s Psychiatry Academy, I heard an excellent talk by Charles Figley, Ph.D., of Tulane University.  The title of the talk was “Thriving in the Face of Burnout and Compassion Fatigue: Practical Tips for Helping Trauma Practitioners.”

Compassion fatigue in therapists is a problem that can accompany moral injury in clients.  Therapist and client work together, trying to deal with behaviors that both of them may feel are repugnant.  In such situations I have come to the conclusion that PTSD therapy with combat veterans is something like a “reverse bootcamp”.  In bootcamp, military recruits are taught to be killers.  In reverse bootcamp I teach veterans how to become loving and caring human beings again.  My stance in this endeavor as a “reverse bootcamp counselor”, somewhat gentler than the stereotypical bootcamp drill sergeant, may help me avoid compassion fatigue.  My therapy method, involving the revision of their traumatic nightmares, may help as well.  With dream revision therapy we are not simply accepting the past in all its horrendous detail, but making adjustments to ease the transition from military to civilian life.

One of my patients said he was changing over from “wolf-man” to “silver fox”, from serial killer to distinguished veteran and elder statesman.  He and I met together in weekly to biweekly individual therapy for more than ten years, about 400 sessions in all.  During this time we dealt mostly with his moral injury, and I somehow managed to avoid compassion fatigue.  My account of our therapy together (for which he has given his written permission) takes up an entire chapter in my book.

Prior to coming to see me, this client had made several serious suicide attempts.  During our 10+ years of therapy I hospitalized him at the VA a few times when he became acutely suicidal and/or homicidal.  Our therapy saved his marriage, and may have saved his life (and the lives of others).  He gained quite a lot of weight and became active in Overeaters Anonymous (OA).  He turned his significant energy and persuasive power into his work as a spokesperson for OA.  He managed to lose much of the weight he had gained.  His 20+ years of sobriety from alcohol and his experience as a sponsor in Alcoholics Anonymous (AA) were helpful in this regard.  When I last saw him several years ago, he was not yet fully recovered from PTSD, but he had improved substantially.  He become quite adept at dream revision therapy, as documented in the 41 dreams he shared with me.