Military Moral Injury Psychology Sociology

Veterans Face Traumas Beyond PTSD

518154131_c_largePost-traumatic Stress Disorder (PTSD) has become a familiar and frequently used concept in recent years. Although PTSD is a major issue faced by our returning troops, it has become somewhat of an umbrella term we often jump to when considering psychological injuries in the military and veteran population. This article discusses the lesser-known forms of trauma affecting returning military personnel and veterans.

PTSD

In the DSM-5, PTSD is conceptualized as, “exposure to actual or threatened death, serious injury or sexual violation.” This exposure then produces prolonged distressing symptoms in the individual such as nightmares, flashbacks, or hyper-vigilance. The key distinguishing factor is that PTSD is closely related to a fear response tied to the fight or flight instincts.

Moral Injury

Expanding on PTSD, moral injury focuses on trauma to the moral conscience. Two major definitions have emerged:

1) Brett Litz defines moral injury as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”

2) Jonathan Shay, in Odysseus in America, defines moral injury as stemming from the “betrayal of ‘what’s right’ in a high-stakes situation by someone who holds power.”

Here is a comparison between PTSD and moral injury symptoms as presented in a recent series on moral injury in the Huffington Post:

Huffington Post

Transitional Trauma

This concept is not currently in use, but it is a concept that I’ve found accurately depicts the unique challenges many veterans face upon reintegrating into civilian life. In my research, I’ve found that beyond PTSD and moral injury, as described above, veterans often experience a traumatic transition to civilian life due to the cultural differences they encounter.

Canadian psychologists with the Veterans Transition Program have referred to the problem as a “reverse culture shock” (Westwood, Black, and McLean 2002). Veterans speak of losing their closely bonded “military family” upon leaving the forces and experience a sense of identity disorientation as they attempt to navigate within an unfamiliar civilian world.

From a sociological perspective, transitional trauma is a form of ‘anomie’. Anomie is a concept used by Sociologist Émile Durkheim to describe a society lacking moral regulation. An anomic society lacks the moral signposts that guide individuals throughout their life-course, leaving them without direction to pursue collective goals. In this sense, it is closely tied to moral injury. Rather than alienation resulting from an individual committing a moral offence resulting in self-blame, alienation results when the individual cannot reintegrate into a relatively loosely regulated society that doesn’t provide the same clear sense of purpose and boundaries found in the military.

Sanctuary Trauma

A concept developed by Dr. Steven Silver, sanctuary trauma “’occurs when an individual who suffered a severe stressor next encounters what was expected to be a supportive and protective environment’ and discovers only more trauma.” Although this concept is under-recognized, a Canadian veteran is demonstrating its current relevance.

Bruce Moncur wrote a recent article in the Huffington Post expressing that fighting veteran affairs is like fighting the Taliban. He attributes at least half of his trauma to navigating the vicissitudes of veteran affairs. Sanctuary trauma comes from a feeling of abandonment, the feeling that one was merely used and thrown away when becoming injured. As stated in my post on Canada’s ‘sacred obligation’ to veterans, this was reinforced by the meeting with Veteran Affairs Minister, Julian Fantino, that went “off the rails.”

In Brief

Veterans experience forms of trauma beyond PTSD. New labels allow researchers and mental health practitioners to more accurately pinpoint the source of the issue. By knowing the source of the issue, better solutions can be provided.

Treatments for PTSD may include forms of cognitive behavioral therapy. Treatments for moral injury may include existential/ spiritual counseling. Solutions for transitional trauma may be sought in group therapy, programs that teach entrepreneurial skills, or occupational groups that provide individuals with a new sense of mission. As for sanctuary trauma, the solution is ensuring returning veterans feel they are cared for upon their return.


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8 comments

  1. As one who’s been the subject in studies of this nature all I can say is they’ve come a long way in this field, when even someone such as myself can see some hope on the horizon. Please keep up the great writing, it is much appreciated.

  2. I have studied issues relating to mental health as part of a social work (come social policy) degree, and I have been a user of mental health services. My grandfather also served in WW2. From all of these perspectives I really enjoy reading your articles. Keep up the good work.

  3. I’m just joe-blow citizen…but I felt “seen” and “understood” in your summary. I’m not in the military, nor is anyone else I know. Your diagram shows my perception of a good chunk of our populous.

    You’ve got me thinking…

  4. Thank you for the comment Fraser.

    You can read my thoughts on Maslow in this post: https://steveroseblog.wordpress.com/2014/02/27/the-need-to-be-needed/

    I argue Maslow’s esteem needs are the most fundamental and can only be satisfied by ‘purpose’. In the individual sense, ‘purpose’ is the feeling that one is needed. In the social sense, ‘purpose’ is the existential nexus between Durkheim’s concepts of integration and regulation. Social regulation provides the moral signposts that bind individuals into organic interdependent collectivities that fulfil the need for esteem by satisfying our need to be needed. This is the basis of my concept of ‘transitional trauma’.

    This is an example of an organization that is doing an excellent job addressing this particular issue: http://teamrubiconusa.org/

  5. Sanctuary trauma is a convoluted way of saying that one’s physiological and safety needs (Malsow) are not being met. Without the meeting of these basic needs, the veteran’s need for belonging and esteem will ever be met. So how can the veteran be expected to relate to others (society) around him or her let alone grow as an individual. This seems to contradict Durkheim’s concept of anomie developed years before he published Le Suicide is the result of society providing little guidance to the individual. For the state of anomie to be a factor requires that an individual be a part of society or at the least be influenced by society. A veteran who is still struggling to have basic needs met withdraws from society and those around him/her DSM V D6).

    To further complicate matters, veteran may be seen as being in limbo. They may feel a sense of loss of the military way of life and at the same time a sense of alienation in returning to the society they left hen joining the military. This same alienation may be felt by those who remain in the military. As soldiers, sailors and air men/women constantly move around within the geographical locations and individuals transition out of the military and are replaced the veteran is surround by those with whom there is no shared experience of the intensity of combat. The veteran’s sense of identity is challenged.

    Bruce Moncur’s experience resurrects the arguments from the 60’s and 70’s about the nature of the military. In the classic Moskos/ Janowitz debate, is the military and organisation, profession or an institution? Each has profound implications for the veteran. If an institution then the concept of a social contract with the veteran is valid. A sentiment echo by Veterans Affairs Minister Julian Fantino who said “some have called the work done by Veterans Affairs to be a duty, a responsibility, a commitment, a social contract or a sacred obligation. I believe it is all of those things.”

    However, what Bruce Moncur’s experience shows is indicative of an occupation model of military service; that is, military service is a job, not a calling or a profession but a job like many others in society have. As Bruce notes “the Canadian government’s “insurance company” methods of dealing with injured and maimed veterans only exasperated the stress these soldiers were dealing with.” This is reinforced by “government lawyers denied the existence of a social contract or covenant between the government and the Canadian Forces in response to a lawsuit launched by a group of veterans.” (CBC)

    New labels will have little effect on the treatment of veterans unless there is unison in the obligation to veterans. Right now, there is only conflict. The military seeks to return soldiers to fighting status while others help the veteran with traumas and adaptation to a life outside the military.

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