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The Center for Post Traumatic Growth

  1. We have finally come to understand that individuals who have been exposed to trauma often exhibit symptoms beyond anxiety and hyperarousal. At its core Post Traumatic Stress is more than anxiety and hyperarousal. Deeper core issues which are the most distressing to veterans are unresolved loss, guilt and shame.
  2. Jonathan Shay called these deep emotional wounds Moral Injuries (1994). Litz et.al. (2009), operationally defined moral injury as “the lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations” (p.697).
  3. Most of the existing evidenced based treatments for Post Traumatic Stress either focus on exposure paradigms which rely on systematic desensitization of anxiety and hyper-arousal (Prolonged Exposure and EMDR) completely missing the deeper unresolved loss, guilt or shame or cognitive interventions targeting faulty thinking and the resultant “manufactured emotions” of self-blame guilt and shame. This approach is based on the idea that reasoning through the evidence will help the person to arrive at a logical conclusion about their culpability. However, trauma is not logic al and resides in the limbic system. At its core trauma defies logic and leaves the individual with a deep wound of the soul. Thus, we have found these interventions to miss the core aspect of trauma and moral injury and actually for some individuals are dismissive of their deeper experiences and suggest that if they would just “think right” they would be well.
  4. As far as I can ascertain, only three groups, other than us, have developed methods they believe addresses moral injury directly.
    Brock, R. (2013) the Soul Repair Project—a spiritually driven intervention where she trains faith-based congregations to “listen” to veterans’ stories of moral injury.Tick, E. (2005) uses weekend retreats where veterans share their stories of moral injury and community members “welcome them home”. He also takes Vietnam veterans back to Vietnam to meet with their memories and enemies.Litz, B., Lebowitz, L., Grey, M., and Nash, W. (2015). Adaptive Disclosure-an eight- session cognitive behavioral intervention used with active duty US Marines.
  5. Our Approach: Three phased group therapy developed and used since 2001, focuses on unresolved loss, guilt and shame. Phase 1 Psychoeducation about PTS, Moral Injury, related disorders, and developing coping skills. Phase 1 allows for a non-threatening introduction to trauma, builds therapist credibility and begins the bonding process of the cohort. Phase 2 trauma focus group: Weekly closed group 9 months, 10 individuals, where the letter writing takes place. Aftercare: focus on post traumatic growth. Less frequent meetings (depending on the population). Keenan, Lumley & Schneider (2014). We estimate we have treated at least 8000 veterans using this approach.
    Trauma is a problem of the human condition and occurs between people. We are hard-wired from birth to attach to those close to us to survive. When bad things happen to good people (those we love) and good people (like us) are put in situations in which they believe or have perpetrated harm on others moral injury develops. Therefore, this approach is certainly not limited to combat veterans, but we believe can be used successfully with all kinds of traumatized populations. “Those whose professions take them into the burning building not away from it” (Briere, 2003, training).It is our contention that unresolved loss and moral injury stem from the sudden, violent severing of human connection through traumatic loss or transgression against others.If this is the case, then the healing of these injuries must be in relationship with others. First one must communicate directly with those lost or harmed (the letter is written to the other) and secondly this best takes place in the context of a community of worthy others. A group of those who have lived similar experiences.Unresolved Loss—Violent severing of the relationship with those we love or to whom we are deeply attachedThe sin of survival—Survivor Guilt, surviving when other who are often perceived as worthier do not.Guilt and shame –Violation of deeply held moral beliefs regarding treatment of others. Morality does not exist in a vacuum. Morality exists to codify interpersonal conduct (i.e. do no harm, do not kill, do unto others as you would have them do unto you, sanctity of life…)The most competent compassionate people are the most vulnerable to these kinds of wounds, that which makes you excel is also your vulnerability.Letter writing allows the direct communication between the individual and those lost or harmed. The letter transcends time, space and dimension. The letter is read aloud to the group, a community of worthy others who have walked the same path. The group provides feedback to the individual about the letter helping then individual to process the event more deeply.

The transformation of individuals lost or harmed nearly always occurs through either a dream or a transformation event.  This phenomenon was described by Shay (1994), who stated that providing a narrative can transform distressing re-experiencing symptoms into welcomed memories, allowing the veteran to gain control of the traumatic recollections. We believe, a reflection of the repair to the interpersonal breach. One veteran we worked with described a transformation dream of his best friend. This veteran had often discussed “Sam” in session and stated they had become very close because they were both avid fishermen and frequently talked about fishing to pass the time. The veteran witnessed “Sam” burn to death after a rocket-propelled grenade hit the gun truck he was manning and exploded in flames. This veteran had labeled himself a coward because he thought he had not done enough to save “Sam”. After reading the letter in which he expressed his feelings for “Sam” and asked for forgiveness for not saving him, the veteran reported a dream in which he received a card with his name on the front and a smiling picture of “Sam” on the inside. “Sam” had written about how much he admired and missed the veteran, and that he was well and happy because he was living on a houseboat surrounded by fish. After describing his dream, the veteran looked into his therapist’s eyes and said, “I know where that card came from; it came from Heaven.” Notably, this transformation occurred within the veteran’s own spiritual framework and clearly reflects the shifting perception of his feelings of guilt, as well as the reconnection he established with his fond memory of “Sam”.

As we understand more about moral injury, applications for such an approach, with other populations exposed to trauma, begin to come into focus. One of the biggest problems facing law enforcement is fatigue which results in physical, emotional, behavioral and cognitive consequences (Basinska & Wiciak, 2012; Senjo, 2011). It also puts members and the public at greater risk in the field and generates high monetary costs due to increased risk of accidents, lost work time, and mistakes in work and court documentation. Finally, many officers go out on disability or early retirement due to stress and burnout.  Fatigue is multi-factorial, however addressing PTS, moral injuries, depression, and anxiety will help mitigate overall stress, sleep disturbance and related substance abuse disorders. This will go far in assisting police officers in managing their fatigue and stress overall.

For additional information about Moral Injury, please see The Centre for Post Traumatic Growth at: https://centerptg.org or email: mkeenan@centerptg.org