Agenda 9:00AM – Noon •Showing of HBO Documentary “War Torn, 1861-2010” •Panel Discussion •Breakout Small Group Discussion Noon- 12:50 Lunch will be provided 1:00PM – 4:00PM •Colin A. Ross, M.D. – PTSD and Suicide in the Military •Theodore F. Mauger, M.D. - Unique Ways Current War Injuries Alter The Brain •Chaplain COL Herman Keizer (ret.) - Worship that Addresses Needs of Veterans with Moral Injury 2015 The Hidden 2015 The Hidden Wounds of War Conference Wounds of War Conference
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Agenda
9:00AM – Noon
•Showing of HBO Documentary “War Torn, 1861-2010”
•Panel Discussion
•Breakout Small Group Discussion
Noon- 12:50 Lunch will be provided
1:00PM – 4:00PM
•Colin A. Ross, M.D. – PTSD and Suicide in the Military
•Theodore F. Mauger, M.D. - Unique Ways Current War Injuries Alter
The Brain
•Chaplain COL Herman Keizer (ret.) - Worship that Addresses Needs of
Veterans with Moral Injury
2015 The Hidden 2015 The Hidden Wounds of War ConferenceWounds of War Conference
The Hidden Wounds of War Conference is made possible by the generous The Hidden Wounds of War Conference is made possible by the generous support and contributions made by:support and contributions made by:
• The Problem of Attachment to the Perpetrator• The Locus of Control Shift• The Problem is Not the Problem• Just Say ‘No’ to Drugs• Addiction is the Opposite of Desensitization• The Victim-Rescuer-Perpetrator Triangle
THE PROBLEM OF ATTACHMENT TO THE PERPETRATOR
The Locus of Control Shift
Power
Control
Mastery
Badness
PerpetratorChild
The Problem is Not the Problem
Just Say ‘No’ to Drugs
Addiction is the Opposite of Desensitization
Victim - Rescuer - Perpetrator Triangle
Rescuer Perpetrator
Victim
SUICIDAL IDEATION AND SELF-BLAME AMONG COMBAT VETERANS
The Locus of Control Shift
Pre-Combat Trauma
Suicide as Murder of the Self
Placing Oneself on Death Row
The Euthanasia Model of Suicide
Ross, C.A. (2013) . Suicidal Ideation and Self-Blame Among Combat Veterans.American Journal of Psychotherapy,67, 309-322.
SUICIDAL IDEATION AND SELF-BLAME AMONG COMBAT VETERANS
Survivor Guilt
Self-Blame for Death of a Fellow Soldier
Self-Blame for Deaths of Civilians and for Atrocities
Self-Blame for Being Raped by a Fellow Soldier
Self-Blame for Failure to Protect Loved Ones Post-Deployment
Ross, C.A. (2013) . Suicidal Ideation and Self-Blame Among Combat Veterans.American Journal of Psychotherapy,67, 309-322.
6. Flashbacks - during a flashback event, the amygdala takes control. Has been called an amygdala hijacking. Typically a 3 to 4 hour process to restore equilibrium.
a. Acute behavioral strategies
1. Withdraw from the environment
2. Oxygenate brain by slow, deep breathing
3. Avoid fleeing or fighting
4. Refocus on islands of health (positive memories)
5. Write down feelings and later, process the journaling
1.Restoration of function takes precedence over symptom control.
a. Is your world getting bigger?
2.Regulate the sleep/wake cycle with focus on ‘wake’
a. Generally avoid long acting stimulants - caffeine
b. Modafinil, Armodafinil to promote wakefulness
c. Stimulants (methylphenidate, amphetamines, et.)
Medication TreatmentsMedication Treatments3. Medication classes to avoid
a. Benzodiazepines
b. Narcotics
c. Anticholinergic medications
d. Older antipsychotic medications (movement disorders)
Medication TreatmentsMedication Treatments4. Use medications which minimize alterations in brain
neurotransmitter function.
a. Omega 3 fatty acids
b. Vitamin D3 - target blood level
c. Antiepileptic medication
1) Gamma-Aminobutyric Acid enhancement - gabapentin and pregabalin
d. Memantine - glutamic acid inhibition (lamotrigine does this as well)
e. Amantadine
Questions? Questions?
Theodore F. Mauger, M.D.Theodore F. Mauger, M.D.
REFERENCESKetcham, Mark. Kilgore College Lecture - from youtube.comSilver, Jonathan, neuropsychiatristHammond, Richard - Invisible worlds from youtube.comGoh, S.H. Singapore Medical Journal 2009; 50 (i):101-106 Blast causality, triage, and injury management
Worship That Addresses Needs of Veterans with Moral Injury
3. Importance of Congregations and Communities in Soul Repair
1. Moral InjuryDefinition and Causes
Moral InjuryAn Ancient Wound of War with a New Construct
“Throughout history, warriors have been confronted with moral and ethical challenges and modern unconventional and guerrilla wars amplify these challenges….[T]he lasting impact of morally injurious experience in war remains chiefly unaddressed.”
Moral Injury is disruption in an individual’s confidence and expectations about his or her own moral behavior or others’ capacity to behave in a just and ethical manner.
From “Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy,” B. T. Litz, N. Stein, E. Delaney, L. Lebowittz, W. P. Nash, C. Silva, and S. Maguen, (Dec. 2009) Clinical Psychology Review, 29, 695-706.
PTSD and Moral Injury• PTSD is a fear-victim reaction to extreme conditions that
damage amygdala and hippocampus (limbic brain)
• Moral Injury requires a healthy prefrontal cortex where empathy and moral thinking occur.
PTSD Can Result from Many Kinds of Exposure to Trauma
Has a consistent symptom profile for traumatic experiences:
Nightmares Dissociative episodes Panic attacks Hypervigilance Lack of conscious memory or memory fragments
1818
Aspects of Moral Injury Formation
• Participation in events that challenge core beliefs or have no clear moral choices, including violating moral codes of training in a closed system.
• Use of personal agency that violates core moral beliefs.• Reflection on memories and extreme conditions of extremity• Agony of inner judgment against oneself. • Feelings of grief, anger, despair, guilt, shame, remorse, betrayal,
contrition, depression, isolation, and loss of will to live.• Collapse of moral identity and meaning system that supports it.
Disruption of Two Important Relationships
•PTSD disrupts relationship to world when it becomes unreliable
•Moral Injury disrupts relationship with self when inner moral core is doubted
Military Culture and Moral Injury
• Military culture fosters moral and ethical codes of conduct. In war, being violent and killing are normal. Troops expect and are prepared for violence and killing.
• Still, even prescribed killing or violence may have a lasting impact
• Most service members can assimilate what they see and do in war because they are trained for it.
Uniqueness of Combat as Traumatic Stressor
• Involves multiple events over an extended period of time (7-12 months) with multiple deployments
• Creates a tightly closed system, so actions considered immoral in other contexts are sanctioned and even celebrated (e.g. killing) within rules of engagement
• Requires abrupt transition from one closed system (combat) to a second open system (civilian) with little or no process or support for transition
1818
Morally Disrupting Aspects of War
Reflexive Fire TrainingDehumanization of EnemyKillingSurvivor GuiltGriefEncountering and Handling human remains--major factorParticipation in torture or atrocitiesBetrayal by Authorities Doubt (uncertainty about goals or mission)
Losses in Returning to Civilian Life"War is the foyer to hell; coming home is hell."
--Tyler Boudreau, Packing Inferno: The Unmaking of a Marine • Loss of closest friends; isolation • Loss of unit and closed system• Loss or role / identity / career• Loss of home – relocate off base• Financial losses –• Loss of Weapon - security• Loss of family or capacity for intimacy– discord /
divorce• Loss of community of support – self /family• Loss of faith and meaning• Loss of reason to live
2. Recovery of Moral Identity After War
Individual/Social Dimensions of Recovery
Writing personal narratives; externalizing inner struggle and telling story
Integrating memory/story into larger picture Reconnection with estranged others; veteran
support systems; community service Long-term support and accountability
community
Moral Repair ProcessFrom B.T. Litz, et. al.
Dialogue with Benevolent Moral Authority
Reparation and Forgiveness Fostering Reconnection Long-Term Planning
Dialogue with Benevolent Moral Authority
Important to practice deep, nonjudgmental listening to experiences that precipitated
moral injury, and To offer benevolent understanding of moral struggle,
To affirm core moral beliefs that emerge,
To discuss how reparation might occur in the current context
To offer support for self-forgiveness or forgiveness from others.
Reparation and Forgiveness
Offer opportunities for service to others and ways to make a positive contribution to the lives of others.
Accompany veterans in finding decency and goodness in working for others
Model self-forgiveness and repair of harm—process of making amends
Fostering Reconnection
Encourage discussions of current relationships
• Forming deeper connections
• Strategies for greater openness and sharing of vulnerability and struggle
• Personal coping strategies for inevitable stress and conflicts
• Reflection on broken relationships that can be repaired in some form
Long-Term Planning• As making amends and self-forgiveness begin to take
hold, encourage reflection on the future
• What would they like to see for themselves?
• Who will continue to matter to them and how can those relationships be supported and enhanced?
• What values, beliefs, communities, etc. will continue to sustain them moving forward?
• How will they cope with the challenges, setbacks, and revisiting of war experiences that will come?
3. Importance of Congregations and Communities in Soul Repair
Spiritual Recovery Lamentation for losses
Forgiveness; amends
Transformation; renewal
Reconstruct moral core values and self-worth
Rituals of LossLiturgies for lamentation—dialogic in a monologic world; hold complex feelings; open doors to healing:
Complaint against God
Realization that conversation is with God
Remembrance of divine love and faithfulness
Restores God to soul
Support for Loss Amends
o Ex. Disaster Relief, Refugee Work
o Ex. Peace Missions
o Ex. Neighborhood Service Projects
Forgiveness and Discipleship
Absolution (letting go and moving on)
Transformation and Renewal Rhythms of the liturgical year bring renewal
Transformation via constant repetition of renewal
Vicarious reliving of baptismal rebirth
Sacramental structure of life
Dramatic reenactment of sacred stories of redemption here and now
Reconstruction
Recognition of existence of a moral order
System of meaning where personal life fits
Behavior and moral choices make sense
Joining not withdrawing
Participation in meaning-making in midst of moral ambiguity and difficult choices
Recommended ResourcesBooks:Letters from a Fort Lewis Brig, Sgt. Kevin BendermanPacking Inferno, Tyler BoudreauSoul Repair, Rita Nakashima Brock and Gabriella LettiniThe Unfinished War, Walter CappsLetters from Abu Ghraib, Joshua CasteelOn Killing, David GrossmanShade It Black, Jess Goodell and John HearnWhat It Is Like to go to War, Karl MarlantesRoad from Ar Ramadhi, Camilo Mejia Until Tuesday, Luis Carlos MontalvanThe Yellow Birds, Kevin Powers
Achilles in Vietnam, Jonathan ShayThe Untold War, Nancy ShermanThe Moral Treatment of Returning Warriors in Early and Modern Times, Bernard Vercamp
Websites:Hauenstein Center http://hauensteincenter.org www.conscienceinwar.orgwww.britesoulrepair.orgwww.ivaw.org/operation-recovery
Films:Soldiers of ConscienceThe Ground TruthThe Invisible WarLionessRestrepoStop-LossTaxi to the Dark Side