“Forces beyond your control can take away everything
you possess except one thing, your freedom to choose
how you will respond to the situation.”
— Viktor E Frankl
*
Over the years I’ve tried to explain and describe what a soul wound is. I can only get close to its essence through movies, music, theater, art, and other sensory, ephemeral explanations.
Recently, however, my soul has been brutalized and bloodied by reports in the media on wars and terror attacks, natural disasters, and painful visions of the world in trauma.
My vision of the soul wound is in the terrified or empty eyes of the children who are experiencing the horrors of the world. Those children who bear the outward wounds and filth of a world that allows babies to be harmed in even the tiniest of ways, let alone to bear the burden war—the insanity of others—on their tiny shoulders.
The eyes of the children speak to me of the wounding of a soul. When we are abandoned, neglected, abused, or experience any of the myriad of traumas I’ve described, imagine or envision the eyes of the children. No matter how old we are when grief comes knocking, it is that wounded child who steps up and receives another layer of pain. The soul wound is found in the eyes, experienced in the heart, and throughout the viscera. The soul wound is sometimes quiet and hidden, silenced, and sometimes it screams and screeches and appears bloodied, begging to be acknowledged.
The soul wound is inflicted by betrayal and shame, fear and diminishment. It is a wound so deep that sometimes we don't even know it is there.
Our Deepest Fear
Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light, not our darkness that most frightens us. We ask ourselves, ‘Who am I to be brilliant, gorgeous, talented fabulous?’ Actually, who are you not to be? You are a child of God. Your playing small does not serve the world. There is nothing enlightened about shrinking so that other people won’t feel insecure around you. We are all meant to shine, as children do. We were born to make manifest the glory of God that is within us. It’s not just in some of us; it’s in everyone. And as we let our own light shine, we unconsciously give other people permission to do the same. As we are liberated from our own fear, our presence automatically liberates others.
—Marianne Williamson, A Return to Love
Marianne Williamson is a visionary, a healer, and a talented teacher with profound depth of character. She has taken her history and turned it into a life-changing, world-changing opportunity for others. Nelson Mandela used this brilliant and insightful “deepest fear” quote as part of his inauguration speech. Like-minded and kindred spirits intuitively grasp the truth of this inspiring message.
Research surrounding PTSD and trauma has indicated that traumatic events impact the very essence of a person’s vision of the world and their place in it. Early childhood trauma affects the attachment process and can create a lifetime of relationship difficulties, which can begin in utero and be intergenerational. This leaves many trauma survivors searching for a place to belong; attempting to find a tribe, and to find meaning for their lives, often the military, as first responders, in the church or religious organizations, and often even in gangs.
Traumatic events can impinge on the spiritual, moral, ethical boundaries, and limits of a victim’s soul. This is moral injury, whether imposed by another’s behavior, the code of the tribe, or their own step outside of their moral beliefs. This damage to a person’s vision of themselves becomes far more damaging than the original traumatic assault.
When my husband overdosed and died, I embraced my responsibility that I didn’t save him, that it was my fault that he died. I swam in the deep and muddy waters of shame, remorse, regret, and deep, deep sorrow, believing I was beyond evil and there was no redemption for me. I lived in my addiction for another fifteen years, never sharing with another soul the nature of my wrongs and the deeply held guilt. Fifteen years later, when I read my life story to my group of seven men and our counselor—my confession and all of the actions and behaviors, the pain and brutality throughout my life—I read it like a shopping list, with no emotion. I could always give “the list.”
I finished and looked up to see tears rolling down the faces of those men. They were crying for me when I could not, would not, cry for myself. They heard my confession and absolved me of my sins. I will be forever grateful for those tears. That is the power of the group. Now I can hold sacred space for others and allow tears to flow. That was the beginning of my own trauma work and the healing path of my family.
Traumatic events often create the impetus for coping/survival behaviors and mechanisms such as substance abuse, process addictions, and presumed mental health disorders such as depression, anxiety, OCD, ADHD and bipolar disorder, to name a few. Many of these diagnoses can be traced back to the original trauma event; they become exacerbated by ongoing layers of trauma. Add to this moral injury and it creates a therapeutic challenge for trauma resolution. A timeline created by a client illustrates very strongly the concept of moral injury.
Bradford’s Story:
A BURST OF LIGHT
The following gorgeous work is a timeline created by a client who is also a wonderful therapist, who has experienced moral injury to his core. For years he hid the depth of his struggle even as he helped so many other wounded people as a talented therapist. This beautiful, sensitive, brilliant man has suffered with multiple sclerosis for a very long time, ultimately in a wheelchair with little hope of leaving the chair. This man came to the forest and continued to fight for his place in the world. And fight he did, moving from the chair to crutches to a cane.
The rapport that he developed with his trauma therapist was awe-inspiring. As they partnered in the healing process, he was challenged over and over again to deny and refute the guilt and shame that he carried as a survivor, to understand that there had been a moral injury perpetrated on him over and over again by a cruel and heinous man. The gorgeousness of his timeline belies enough the evil that others imposed on him. You will also see masks that he created later in the book. This is a man who walks today without crutches or a cane. It was stress hormones that made it possible for MS to ravage his body and, as he has found resolution in so many areas, his physical body is healing along with his mind and spirit.
On the pages that follow, Bradford describes the artistic representation of his journey, from trauma to healing.
Panel One
1) Timeline starts from a burst of light (my birth).
2) The three trees represent me and my siblings (older sibling born in July, me in November, and youngest in January. So, the three trees show each season.
3) The two guys in cowboy hats represent my first perpetrators (first two of five). Our parents were best friends, and all worked horses together. These two brothers were sixteen and eighteen, and I was five.
4) The Bud Light bottle represents the alcohol that the two brothers used to help “calm me down,” or “get me more in the mood for it.” Again, age five.
5) The arm reaching up out of the “river” of alcohol represents a sixteen-year-old girl who drowned less than 10 yards from me in the river, shortly after she took me to the shore for my own safety. I was five.
6) There is a coiled-up snake. I have the “Black Irish Luck,” and have been bitten four times by poisonous snakes over the years. Copperhead at age four to five, cottonmouth at twelve, and two times by a timber rattlesnake at thirty-seven.
7) The bleeding hand . . . this is a toughie. When the two brothers initially started raping me, I screamed and fought back. Repeatedly they threatened me. If I didn’t “play along” or “calm down,” they were going to “Show me what real pain was.” They told me that they would make sure “I never scratched, or fought back” again. So, after I scratched the oldest brother on his chest, they held me down and drove a nail through my hand into a board. They had stuffed my mouth with a sock (I think). I was in absolute shock, and quite honestly numb to the fact that they went ahead and continued raping me, while I was nailed to a board. Again, I was five.
(Note how the yellow river of beer/alcohol turns to a red river of blood. I primarily did this because the blood represented pain/shame/distrust that carried with me throughout my life.)
Panel Two
1) You can see in the upper left-hand corner a pill bottle. Somewhere around the age of seven, the two brothers had me take acid, “rush,” cocaine (once, it didn’t do very well with me at this age), a variety of pills, marijuana, and even “shrooms.” (The mushrooms made me vomit. I didn’t have to do it again.) The main pills that “worked” on me, for their purposes, were the pain pills and benzodiazepines. Of course, alcohol was always used on me and really became one of my closest friends. It helped numb me out and cope with it all. This all started between ages six and seven, and continued weekly, until they stopped the first years of the rapes when I was about twelve or thirteen.
2) Lower left-hand side represents my “Keeper of My Night Terrors,” My mouth is covered because I was taught from the earliest years to keep everything a secret—no matter what. Lie, cheat, whatever, just never tell what you know.
3) The minister baptizing in the river represents my loss of all trust/belief in the institution of organized religion. In fact, the minister doesn’t baptize these people; he drowns them. Their drawings represent how perverse the church leaders and hypocritical people are. I would rather believe in a flower; its beauty is real. Oh, did I happen to mention that the oldest of the two brothers became a minister (yet, he later rapes me for an additional six years from sixteen to twenty-two) and during my three-year break from the brothers, they told another eighteen-year-old in the Protestant church they attended, and he lured me out for a “fun night of mudding” in his huge, yellow, jacked-up pick-up truck, only he took me out to a dried-up lake and raped me. He went on to rape me for about a year. Later on, he was convicted of raping six local boys and given forty years in prison. I was number seven, but no one knew, because I lied to the cops when they asked. After all, I was trained early on how to keep secrets. I was quiet, depressed, and drinking (secretly, of course). Then, things started to look up! I got a job—working at the local Catholic church. However, I had to quit after a month of working, because the priest had me and another boy do sexual favors for him. The other boy went on to “live” with this priest, because his home life was so chaotic and not a “good environment.” I say all of this to explain why I have such distrust and hurt, when it comes to the institution of the church, or religious people (no matter what faith).
4) The bent license plate represents a car wreck that left me in a coma for quite some time. The recuperation period was almost a year. During that year, mainly because of my quiet disposition and obvious depression/anger that I had along with the physical problems, I was recommended to a psychiatrist. This psychiatrist saw me twice a month for over two years. He dove into a lot of my rapes, and any/all sexual areas of my life. He knew everything about me. Abruptly, his office called and said that I had been “Discharged from his care. If I needed further assistance, they could give me referral contacts.” I thought that I had done something wrong. Less than a month later, he called my house and asked me if I would like to join him and other men, who would be working on his lake house. Said he knew I could use the extra money for school. I agreed and went. There were no other men. There was no work. He knew exactly what he was doing; he was my fifth and final perpetrator. These rapes went on for almost a year. Many years later, he had a stroke. His oldest son and daughter-in-law asked me to join them at the lake house. I had horrible reservations, but I went. They knew everything. In fact, they had seen everything. The psychiatrist had secretly video recorded all of his sexual exploits. I was only one of many, and many of those were his clients. We destroyed the tapes, and I dove deeper into my shame, blame, anger, drinking, and using. I’m saying all of this to point out: who the hell could I trust?
5) So, above in the painting, there is my grandmother who took me in at twelve. She and my grandfather took me in, because they said “There are only so many ‘accidents’ a child can have.” They knew there was abuse, but had no idea how bad. My grandmother helped me see the beautiful things: flowers, nature, unconditional love. The skeleton on a horse (right-hand corner) represents Death. My grandfather died when I was twelve, crushing my world. He was the only positive male role model I had.
6) The bird hunting represents the fun activities that my grandmother helped me to find and enjoy, especially hunting and fishing. They were escapes from everything else, especially the bad.
7) The kangaroos represent my process addiction with sexual addiction. Between all of the rapes and trying to date, I have always maintained a very open relationship to the idea of being bisexual. Others may judge me for this, but they have not walked in my shoes. I had no choice to the traumas that I suffered. However, I have had choice in seeking trauma repetition in an effort to find that level of intensity. That has been a choice. My favorite phrase is “Labels are for clothes.” I simply say, “Yes, I am sexual.” My therapist once told me, “I believe that you would fuck a kangaroo if it came hopping across the campus, if you could catch it!” My response was, “How fast is it hopping?” So, to this day, he always asks me how things are going with the kangaroos.
8) The two turtle doves represent one of the happiest points in my life, my marriage.
9) The butterfly represents the birth of our daughter. In the midst of five miscarriages, having our daughter was a huge blessing.
Panel Three
1) The pocket watch and chain, represent time and you will notice they cross over to each panel.
2) This panel is where I try to show in my timeline how things are starting to come together, get resolved, and simply look brighter.
3) The pig with wings on the launch pad represents the fact that someone said that I would get clean and sober, “When pigs fly!” Well, after thirty-nine years of using, I am now three-and-a-half years sober!
4) The two boys at the river represent my Inner Child and my Hero (this person has changed over the years . . . it might be Billy . . . and then the next month, it might be Mark. . . . And the list goes on. My Hero is now any positive male that I can find, respect, love and know that he will help my Inner Child recover from all of the men who have abused me in life). The Hero helps the Inner Child to let go of things/feelings/thoughts that have been haunting the Inner Child, such as “Ego, Hurt, Anger, Fear and Shame.” As the Inner Child and Hero release these boats of trauma . . . the boats go down the river . . . and the blood turns back to normal . . . the blue-green river water and the boats are eaten by a Florida alligator!
5) Elton John singing and playing the piano, represent my mantra “How wonderful life is while you’re in the world!” I was asked by my therapist to pick a theme or mantra that I would like to use as my own personal life/attitude goal. I became suicidal. In fact, had several attempts. I mean, why the fuck not? Look at this “fun life” that I had been put through. That was the way I thought. I believed that I deserved any and all bad that could ever come my way. I was damaged goods. I can’t really say that I loved anyone else, not really. How could I? I fucking hated myself. Then, with many, many years of help, I know that life is wonderful as long as I’m in the world!
6) The rose garden and stone with joy on it represent my meditation garden, where I spend many hours doing meaningless things, and loving the fact that I am able to be present with myself. I am beautifully made, and I am worthy—just as I am today!
7) The Wilson volleyball by the garden represents how a lot of people say that they have all of these tons and tons of awesome friends (when the reality of their entourage of friends is not that loyal a group of friends at all). All I need is Wilson! Give me one or two good friends, and I am incredibly blessed. I have learned (by harsh lessons) that not everyone deserves my trust, friendship, or my time. I don’t wish them ill; I just wish them to stay “over there!”
8) The boy meditating toward the “Sun of a Bright Future,” represents me finding these new enjoyments of life . . . at the middle of my life. I never painted. I never gardened. I never did meditation. Shit, I was too busy getting high and drunk, running from perpetrators and police! (All of this is to say I learned that I am never too old to find happiness, peace, and enjoyment.)
9) All of the items in the far right-hand side (the gnome, cat, jackass in a suit, and sign) were all ways that I was able to take a stressful situation at the time and make fun with them. The jackass represents the corporate part of the business world. You can put a suit on a jackass any day and call it COB (Chief Officer of the Barn)—he’s still just a jackass in a suit!
10) The sign represents any and all roads where I’ve traveled, and really do not want to travel again. Lessons learned! “Dangerous Road! Watch for potholes, sinkholes, and assholes!”
11) Finally, above Elton John’s piano, you see a man, facing the future, butt/ass naked, arms raised up in the air, saying, “Well future, here I am! Bring it!” And a key point worth noting: on this wise man’s ass, which is facing the past, is a tattoo of a pair of lips! (Which is Beagan, but now I have the same tattoo! Ha!) Those pair of lips are letting the past know exactly how the new me feels about the past and how I am looking to a brighter day ahead!
A Spiritual Dilemma
Moral injury, the soul wound, creates a spiritual dilemma and as clinicians we must face this with a very full toolbox which includes healing and cleansing ceremonies. The shininess of our spirit begins to tarnish with each assault on our sense of self. Spirit becomes tarnished, dulled by deep pain, sorrow, and doubt about the essence of our goodness. Self-doubt and low self-esteem enter our spirit and cast a darkness that must be lifted to heal, then polished vigorously so we can once again share our shiny brilliance, and claim or reclaim the essence of who we authentically are.
The term moral injury is believed to have been first used during the Vietnam War by marine veteran and peace advocate Camillo Bica, PhD, who wrote and spoke about moral injury experienced by soldiers as a result of their actions, or being powerless over the actions of others, that were outside their personal moral/spiritual boundaries.
As a result of Vietnam, PTSD and moral injury have been explored, researched, written and spoken about. This has led to an understanding of the impact on humans and humanity. We will discuss both, define both, and see where they come together and where they must be treated differently.
In an article appearing on the website of the National Center for PTSD entitled “Moral Injury in the Context of War” by Shira Maguen, PhD, and Brett Litz, PhD, moral injury was described this way:
Like psychological trauma, moral injury is a construct that describes extreme and unprecedented life experience including the harmful aftermath of exposure to such events. Events are considered morally injurious if they “transgress deeply held moral beliefs and expectations.” Thus the key precondition for moral injury is an act of transgression, which shatters moral and ethical expectations that are rooted in religious or spiritual beliefs, or culture-based, organizational, group-based rules about fairness, the value of life, and so forth.
In findings from The Moral Injury Project at Syracuse University, researchers Kent Drescher, David Foy, Caroline Kelly, Anna Leshner, Kerrie Schutz, and Brett Litz defined moral injury as “disruption in an individual’s confidence about one’s own or others’ motivation or capacity to behave in a just and ethical manner.”
Drs. Maguen and Litz determined that the aftermath of moral injury may result in “highly aversive and haunting states of inner conflict and turmoil including: shame, which stems from global self-attribution ‘I am an evil, terrible person; I am unforgiveable,’ ” and guilt.
Other symptoms they report include anxiety about possible consequences, and anger about betrayal-based moral injuries. Typical behaviors can include:
• Alienation/social instability caused by breakdown in standards and values
• Withdrawal and self-condemnation
• Self-harming (for example, suicidal ideation or attempts)
• Self-handicapping behaviors (for example, alcohol or drug use, self-sabotaging relationships, etc.)
Maguen and Litz go on to say moral injury has been posited to result in re-experiencing, emotional numbing, and avoidance symptoms of PTSD. In addition to grave suffering, these manifestations of moral injury may lead to under- or unemployment, and failed or harmed relationships with loved ones and friends. PTSD and moral injury overlap, but moral injury can stand alone. As an industry we must begin to understand the healing process for moral injury (whether standing alone or in concert with PTSD), and the very serious consequences of not addressing it and finding resolution.
Almost all of the research is based on the experience of combat veterans, but I would like to offer my experience with moral injury in survivors of trauma. We have a long and deep and healing history working with veterans, and that has led to my conclusion that moral injury impacts many trauma survivors, usually those with the deepest shame and guilt; often those who cannot see or believe in their innate goodness; typically those with a higher moral, ethical, and spiritual code that they believe to their core that they have broken and dishonored, and thus are beyond redemption. What are those horrendous acts that they believe they have committed?
1) Heading the list is childhood sexual abuse, the moral injury experienced by the child. Very young children have a sense of right and wrong, and good and bad. Although they are the victims, and the injury has been perpetrated upon the child, children nevertheless embrace the concept of their “wrongness,” their own evil. The child may not even have the words but the assault is embraced as their fault. Too often the perpetrator reinforces that belief with statements such as these:
It’s your fault, you made me do it.
You have bad blood.
You wanted it.
If you don’t come with me, I’ll take your sister, brother.
I’ll kill your family.
No one will believe you; they know you’re bad.
A child embraces that guilt and shame and believes they have sinned, and they are haunted by sorrow, believing they are not worthy.
2) Abortion. Many years later clients come to us who have had abortions and are in such pain, believing they can never be forgiven.
Often when a woman is sharing her painful story, the men in the group will break down and talk about the abortions they insisted on, not supporting the mother, or not being told about the pregnancy/their child until after the abortion. Sharing that pain, shame, and guilt can be cathartic, especially when we add a cleansing ceremony.
3) Other events that create moral injury are injuring or killing another human being, or being unable to save someone.
4) Giving up a child or being forced to give up a child.
5) Often adoptees embrace the deep primal wound of being given up.
6) Starting someone else on drugs. Witnessing an overdose or suicide.
7) Infidelity or keeping the secret of infidelity for a parent.
8) Survivor’s guilt for surviving when others did not.
These are all moral, spiritual dilemmas and there are others that can be added to the list. Moral injury creates a deep sadness and sorrow, a belief that one can never be forgiven.
Overdoses and suicides have grown at an alarming rate. I believe trauma survivors who attempt or commit suicide often are in this very deep, dark place of inability to forgive themselves, and they also believe that their God could never forgive them. Moral injury was originally defined as a result of veterans’ experiences. I propose that just as the military helped us to see the universality of PTSD, so can we see that moral injury spans all sectors of trauma. As clinicians I would pray that we look more closely at that spiritual belief that drives our clients to despair—the soul wound. We can create an opportunity for a state of confession and self-forgiveness, for cleansing, healing, ceremony, and for forgiveness.
Addicts who enter a twelve-step program are asked to do the “steps.” Step Four invites us to write a searching and fearless moral inventory; Step Five asks us to admit to God, ourselves, and another human being the exact nature of our wrongs. For many this is the beginning of the “sunlight of the spirit” entering our lives. But many others are terrified of this step and never get there, continuing to be mired in guilt and shame. It’s just the beginning of the journey of trauma resolution.
As trauma therapists, we provide slow and steady intensive treatment, building rapport and trust, remaining without judgement, and being present as a witness in a safe and loving space. In that space, survivors may begin to heal.
That moral injury that so many experience is never spoken until finally someone asks the questions: What are the things that you believe you can never be forgiven? What does that mean about your place in the world, your vision of yourself? The answers to these questions may change the course of someone’s life.
David Wood has written an incisive and compelling series in the Huffington Post titled “A Warrior’s Moral Dilemma.” It speaks to the reality of the overwhelming numbers of our troops who experience not only PTSD but moral injury, and the toll that this takes on veterans and their families.
I invite you to see trauma survivors, particularly those with layers upon layers of trauma complicated with moral injury, as the warriors that they are. Their stories and their work will provide a vivid picture of the courage it takes to walk through the morass of complicated grief and fear. Many, if not most, of our combat veterans become members of this tribe.
I would also suggest that the families of trauma survivors experience their own level of PTSD as they attempt to understand the changes in mood and behaviors in their loved one. Often they see the behaviors in moral terms—good or bad, right or wrong—when in fact they are survival, soothing behaviors. As we work with trauma we must include the family. There are so many puzzle pieces that begin to fit together when we explore generational and intergenerational histories, and examine traumatic events that may be two to three generations back; yet they continue to impact families in the present.
For instance, I would like to see a survey or research project identifying the number of veterans of Iraq/Afghanistan whose parent was in Vietnam, grandparents or relatives who may have been in World War II, and the impact that had on their lives as children and adolescents, their emotional connection with those family members, the messages they received. I’ve found a pattern of trauma reenactment among the vets I’ve worked with. Granted, that’s a relatively small number but I wonder . . . If we were to do a large study I believe it would be eye-opening. I believe that this is an international/universal phenomenon.
David Wood writes, “It is what experts are coming to identify as moral injury; the pain that results from damage to a person’s moral foundation. In contrast to Post-Traumatic Stress Disorder, which springs from fear, moral injury is a violation of what each of us considers right or wrong.”
Wood continues: The diagnosis of PTSD has been defined and officially endorsed since 1980 by the mental health community, and those suffering from it have earned broad public sympathy and understanding. Moral injury is not officially recognized by the Defense Department.”
Wood continues, “It is not fear but exposure that causes moral injury—an experience or set of experiences that can provoke mild or intense grief, shame and guilt. The symptoms are similar to PTSD: depression and anxiety, difficulty paying attention, an unwillingness to trust anyone except fellow combat veterans. (A trauma bond is created.) But the morally injured feel sorrow and regret, too. Theirs are impact wounds caused by the collision of the ethical beliefs they carried to war and the ugly realities of conflict.” (The drive to survive.)
In 2014, David Wood wrote that “the definition of Post-Traumatic Stress Disorder doesn’t cover all the symptoms of moral injury, the lasting wounds to the soul caused by participation in morally ambiguous combat events.” The diagram Wood created identifies the symptoms of each, and those that overlap.
I would also add that PTSD in the military still carries an enormous stigma, which is often why so many do not seek treatment. If they do, sometimes they avoid the VA for fear of stigma on their record or reputation.
So for all of our warriors—military, refugees, or victims of sexual abuse, abandonment and neglect, medical issues, domestic violence, natural disasters, and the multitude of other traumatic events—our role is to recognize the differences between PTSD and moral injury, and the areas where they overlap, to create the appropriate healing modalities and experience. This is illustrated in Wood’s diagram on the previous page.
Warriors All
Some may criticize that my proposition demeans the experience of veterans, however, those warriors relate at a very intimate level to the pain, sorrow, remorse, and horrendous, terrifying, and de-humanizing stories of their peers. In intense trauma treatment groups, they share the experience of body memories, flashbacks, and hypervigilance: sitting close to a door with back against the wall anticipating the next assault, vivid nightmares, endless sleepless nights, and night terrors. Whether veteran or traumatized child who’s now an adult, they are disabled by these experiences, unable to form trusting relationships, forced to create other coping/survival skills to numb the pain, often suicidal or in suicidal ideation, and both convinced that they are not worthy to be forgiven.
Vets relate to and recognize the universality and commonality of events, the emotional and visceral response to those events, and they share the courage and drive to survive and heal with other trauma clients. The group encourages and challenges one another to look at all the layers of their lives, including combat. A group process is a rich and vital part of trauma resolution. Just as veterans opened the world’s eyes to PTSD, so now can they open our eyes to the depth of moral injury that consumes most wounded survivors.
The trauma-healing model we’ve embraced has been expanded and creates an additional layer of the healing process. We often speak of forgiving yourself, perhaps without fully understanding the depth of what that means. I invite survivors, families, clinicians, and recovering people everywhere to embrace our responsibility and awareness of moral injury and the part it plays in the lives of survivors.
As illustrated on David Wood’s diagram, both PTSD and moral injury share the signs and symptoms of anger, depression, anxiety, insomnia, nightmares, and self-medication with alcohol and drugs. To these I would add all substance and process addictions such as sex and relationship addiction, gambling, eating disorders, self-harming behaviors, and any compulsive behaviors that flood the brain with soothing neurotransmitters. Also mood disorders, which often become the place of comfortable un-comfortability, are familiar friends for many trauma victims. I rarely see a person with just one survival/coping mechanism.
Wood indicates that PTSD symptoms also include a “startle” reflex, memory loss, fear, and flashbacks, and that moral injury includes sorrow, grief, regret, shame, and alienation. Without research to prove it, I believe through plenty of first-person anecdotal experience with clients, that there is much more of an overlap for PTSD beyond the visceral, cellular symptoms. I believe anger and rage often hide sadness or sorrow, and depression can be anger or remorse turned inward. Again, I have no proof, just years of observation. It’s in the relationship that we build with clients that leads us to ask the deeper spiritual identity questions that may lead to forgiveness and redemption. After hearing their trauma stories, I’m astounded that they survived. I ask, “How did you survive all of that? Who were the people, animals, places, and things that helped to raise you up, help you to survive?” These are the same questions I would ask any warrior.
So what does moral injury and the healing from moral injury look and sound like? I offer you the work of several people who willingly offered their very personal and deep healing work, hoping to give at least one person hope, which would make it feel worthwhile.
The first work is done by Kate, a young woman who had been in multiple treatment centers and struggled greatly with substance abuse and self-harming behaviors. She was angry and acting out in destructive behaviors. As you view her art—poignant, visceral, haunting—and read her letters to her “Little Me,” it becomes clear why her struggles have been so endless. I won’t tell her story because she gives an emotional and incisive view of her path herself. This client worked hard to push people away, to be thrown away again, which is the reason a good trauma therapist fights for the time it takes to build trust with such a wounded person. It takes time and a lot of energy and engaging the community in building empathy and boundary setting. Discharge cannot be the first or second choice in most cases.
During treatment, clients are going to act out and this is what a good treatment center wants the client to do. This way, the therapist can work on the underlying issues causing the acting out. So, discharge for acting out in most cases is not the go-to recourse of a good treatment center.
Kate’s Story:
DEAR LITTLE ME
Dear Little Me,
Hey there kiddo. This letter is kind of hard to write . . . I’m so hard on myself, and at the moment feel a little silly. But I think you deserve to hear this. I want you to know that I’m proud of you. You endured so much crap and pain. You were so strong, stronger than I ever realized. Know that what those men did to you wasn’t your fault. I know that you’ve questioned so many things. Did you turn him on? Did you actually want it? Was it your fault? No child, you did nothing to deserve those awful things. They were sick, nasty, twisted men and women. They made you believe it was your fault, so that way you wouldn’t tell. Things were taken from you. You were robbed. You weren’t left with a choice. They controlled you. You were just an innocent little girl, who up until the age of five knew nothing but Barbie dolls, Power Rangers, Barney, painting nails, playing in the dirt, jumping in the leaves, and being silly. Then someone took that innocence away. One after another they stripped it from you, causing you to grow up way too fast.
You started drowning yourself in every activity you could: Girl Scouts, church activities, Lads to Leaders, piano, and the biggest thing: sports. Sports became your life, your escape. And you were good at them, especially softball and volleyball. You always had people there cheering you on, and teams were scared to go up against you. You practiced all the time to make sure you were good. It was a great release and distraction. Something you could control. You also made good grades in school. I know you felt like you had to be perfect at things, but it is okay that you made mistakes every now and then. Nobody is perfect. I’m proud of you for the grades and succeeding at sports. But even if you didn’t have those, I’d still be proud. I’m more proud of you for surviving, for doing whatever it took to live through all of that. You were brave. You were brave to take on as much as possible and lessen the load for others. You were brave to pull the trigger on yourself. I know you wish that you could’ve protected your sister more, but sweetie, there was no way; you couldn’t. He controlled you, you didn’t have a choice. I know you think there must’ve been some way, but there wasn’t. You did your best. You kept her safe as long as you could; you saved her from the “worst” of it. Even if you had said “No,” he would’ve just beaten you and still gotten to her . . . he always got what he wanted. So I’m proud of you for doing what you could. I’m not disappointed in you. I love you. I’m sorry that so many things happened to you, I really am. I’m sorry that nobody stepped in and protected you. That nobody saw through your shields. No kid should ever have to endure the things you went through. I wish you would’ve gotten more hugs and more I love you’s. You could’ve used a few more.
Here’s another story written as part of a treatment assignment, graciously shared by Kylie.
Kylie’s Story:
AM I WORTHY?
Am I worthy? If so, why? When am I . . . all the time or sometimes? What am I worthy of? Was I more or less worthy in the past or present?
There are so many times when I don’t feel worthy, of anything. The voices and the lies come back repeatedly telling me that I’m worthless, useless, damaged—not good enough. But then, when I pull myself out of that cycle and take a step back, I realize that all those words are lies. Nasty, filthy lies that put your self-esteem and self-worth in the toilet. I know deep down that I’m worthy. I’m worth more than silver or gold, or any dollar sign. I’m worthy of love and respect. I deserve to be treated right, with compassion, kindness, gentleness, and patience. I’m worth the encouragement. I’m worth people’s time. Why? Well, first of all because I’m a human being just like everybody else . . . no greater, no less. Just like everybody.
I long for that intimate relationship with people. I long for closeness, acceptance, and love. I deserve to be seen as equal, not as somebody to be run over and trampled on. I feel worth people’s time and them taking a chance on me because I truly do want to do better. I want to heal. I want to be healthy. I want to be free.
I’m working hard and trying my best. Things don’t always click the first go-around, and I know sometimes I can be stubborn, but I eventually get it. I don’t just goof off all the time. I’m not wasting the help. I listen intently and try to soak everything in. I’m worthy because I know deep down, I’m a good person. I’m compassionate, empathetic, loving, caring, a good listener, trustworthy, honest, usually patient, encouraging, and hopeful. I want to be able to help people. I want to take what I’ve already learned, and am continuing to learn, and pay it forward. I want to help people be the best they can be and have a better life.
I also think I’m worthy because I’m a child of God. I’m his daughter. No matter what happens on this Earth, I will always be his; he won’t leave me and will always love me. He tells me I’m worth it. He sent his son to die for me, so I can be with him someday. He wants a relationship with me. The creator of all things, wants a relationship with me! I don’t feel worth that, but because of that, I know I am. There’s nothing greater than that.
Logically, I know that I’ve been worthy my whole life. But then my head gets in the way. I was worth everything before age five. From ages five to fourteen, I honestly don’t know. There’s a part of me that knows I was worthy and deserved better than how I was treated. But then the other part of me feels like I wasn’t worth shit. But that time frame screws with my head a lot. And now I’m starting to feel worth it again. Feel worth time, intimacy, and love. I’m worthy.
We expect clients to act out in survival behaviors, especially in treatment. We have taken away their substances and invited them to go to the pain. Self-soothing is the rule of thumb, the rule of survival for trauma survivors. We expect clients to relapse in eating disorders, self-harm, sex and relationship addiction. The work is much more intense for staff but the payoff of recognizing how our people protect from the pain is a juicy therapeutic opportunity to prevent relapse by identifying all the behaviors that pop up. Rarely have I witnessed just substance abuse, or just sex addiction, or relationship addiction, or just eating disorders, or self-harm. We have many ways to protect ourselves from pain. In recovery I buy shoes, lots of shoes, and my neurotransmitters pop and ping in the same way; and I get relief from fear, loneliness, and insecurity.
I would venture that relationships and sex addiction, but more so relationships, are the number-one precursor to relapse because disordered attachment and inadequate socialization drives much of our trauma responses. The relationship between a baby and its caretaker determines the child’s ability to attach to others in a healthy way. If a healthy, secure attachment is not created, then the attachment style is “disordered.” Hence, clients reach out to other clients in attempt for connection. There’s a saying among trauma residents: “Wounded people wound people,” and so rarely do those “treatment romances” heal one another. But once again, a seasoned trauma therapist can create an opportunity to connect the original traumas with the drive for relationship, any relationship, and more often than not, a replica of the original wounding. If we discharged those folks they would go on to the next treatment center and repeat the pattern again and again.
Excellent trauma treatment is intense, exhausting, riveting, and rewarding beyond measure. But the commitment to do this work at the necessary level and the intimacy with trauma is often too intense for many programs. I applaud them for knowing what they do well and staying in integrity. Trauma work is a new level of commitment. A trauma program cannot be just one or two groups a week; it must be immersed in the milieu and it must contain visceral, cellular, sensory, body-centered, experiential modalities. The can include modalities such as psychodrama, Somatic Experiencing, art therapy, and music therapy, to name a few. The clinical staff needs to include experts in eating disorders, self-harm, sex and love addiction, and substance abuse. All should be cross-trained to understand each of those areas at a more granular level. That means everyone trained in trauma, Somatic Experience, and several in brain spotting and EMDR, psychodrama, and equine-assisted ceremonies of many cultures for cleansing (created by David Grand as an additional somatic therapy), lifting up, forgiveness, atonement, and the opportunity to find a spiritual path if possible for the individual.
Some more works from clients who have had soul wounds and moral injury follow.
Kylie’s Poem
I am chained to a hate of some kind I lost myself that day
I lost all trust
It was all too much for my heart to take
Too much for my mind to forget
Will it ever erase?
I’m lonely inside
Even though you can’t always tell I’m reaching out
For what . . . a hand, love, acceptance, and understanding
I’m trapped inside my own mind I’ve felt the strength of demons
If God made the day
Then the devil made this night
My depression grows deeper
Pulling me apart at the seams
Causing me to unravel and fall to my knees
Wondering desperately, how much worse can it be?
So I’m alone again
Another night of crying
A night of hiding
Is this ever going to end
I look in the mirror every day and see a girl
A girl who is staring back at me
I don’t know who she is anymore
Cause she’s not the girl I wanna be
I try to hide the pain
And carry on
Don’t let anybody see
That I’m not what I’m pretending to be
I put on a smile
When I’m falling apart I say, “I’m okay”
When really pain fills my heart
*
This young lady was able to go to the darkness and share her trauma story with her group, participate in psychodrama, Somatic Experiencing, and other experiential, visceral, cellular, sensory therapeutic interventions that took her to the five- to fourteen-year-old little girl, feeling the pain, confusion, anger, and shame, and have a cathartic release. The work continues and her ability to identify the woundedness is enabling her to begin to find her worth and value. As you can see with the progression of her words, she is slowly rubbing the tarnished spirit and finding, slowly, her shininess. That doesn’t mean that she is “cured”; it means, like most of us, she is on the path. And she offered us her favorite quote by Marcus Aurelius, “The best revenge is to be unlike him who performed the injury.”
I often approach clients by asking, “How are you feeling?” The response is often, “I’m in the black dot.” (See page 124.) I share how proud I am of their courage, that they are embracing the feelings of pain. Only then can we be free of the shadow of our traumatic experiences. Feeling brings us through the fight, flight, and freeze process to resolution. The trauma doesn’t go away but it has less power, less of a charge, and doesn’t have to rule our life and choices or behaviors.
Tessa’s Story:
BLOODY DIAPERS
“Bloody diapers, goddamned bloody diapers. I was just a little girl, scared and angry all the time. My three brothers and my drunken father, but I was just a little girl, only three years old.
As a therapist, what am I supposed to do with that? Where am I supposed to go with that ugly story? I never told, never told, not until you. Please help me!”
Tears spilling down her face as she panted through the terror. Her raging, sad eyes matched the wild and crazy black, curly hair. Tessa let her anger show, always loud, obnoxious, and rude. She never held her tongue; worked at pushing people away. It all makes sense, of course. How else could she protect herself? A chronic relapser, a respected professional, in and out of treatment.
She tells me, “I’m not ready to do this work yet, but my little girl in my soul is demanding help. What can I do?” Tessa told me what she needed—her little girl not to be angry or frightened. The answer came to me.
“Tessa write a letter, tell little Tessa how much you love her, that you will protect her, and that she has a right to be angry. Tell her you are not ready yet; that you are preparing yourself to do the work, that you told the secret today for the first time. Soon, it will be soon.”
Tessa wrote that letter right there in my office and she read it to her angry little girl who became willing to wait and give her peace. As she read the letter, tears streamed down my face.
Tessa asked: “Why are you crying?” I said, “Someone has to cry for that little girl,” and we both let out a huge breath. That letter is still in my possession. That was a piece of trauma resolution!
The family never talked about this horrendous secret but Tessa was able to heal that pain. The events don’t go away but they get less powerful and have less of a charge. Tessa took me to that dark place with her in the next year. She hadn’t been able to stay sober until she told that awful, shameful secret.
Signs and Symptoms of Trauma
When we think of trauma and trauma reactivity, most people think it is a disorder of the mind. While this is partly true, the majority of the disorder is in the nervous system. At its core, trauma is an event or series of events that triggers our survival instinct. When this happens, we automatically respond in fight, flight, freeze, or acquiesce mode. When PTSD or PTSD reactivity occurs, our nervous system is reacting as if we are still in danger. We go in and out of survival reactions. These reactions are automatic and exist in the most primitive part of our brain; they exist to try to save our lives and we have little to no control over them. If our brain determines we are in danger, we simply react in whatever manner the brain decides gives us the best chance to survive in that instant.
The easiest way for most people to understand this is a traffic accident. Most of us have been in a car accident at some point in our lives and can relate to the experience that occurs in our bodies. There’s usually a point as the accident occurs that everything starts to slow down, our senses are sharper for those few moments that feel much longer. This is the mind and nervous system reacting to enhance our perceptions and give us a better chance to react and survive. Those of us who have experienced this also know it’s completely automatic and out of our control. At some point after the impact, or at the point of impact, our perceptions speed back up and we may shake, which is our body’s attempt to throw off the shock to our nervous system.
What follows for many is that for the next day, few days or even longer, we are nervous in the car, we may flinch and react when someone gets what feels too close. If the accident was at a stoplight or on the freeway, we may be more anxious or reactive in those places. If we see a car similar to the one that was part of our accident, we may be more on guard or skittish. This is all trauma reactivity: our nervous system telling us we are in danger again, even though this may not be the reality. For most of us our reactivity passes, our nervous system normalizes, but if PTSD occurs then the reactivity remains or comes and goes. This survival reaction is meant to keep us alive. It’s a drastic measure in an instant of danger or perceived danger that takes a tremendous toll on the body, nervous system, and psyche. When someone experiences this reactivity on a constant basis, it puts a horrible and stressful strain on our systems.
One way to think of it is like a balloon. You can fill the balloon with only so much air before it explodes. We have to let some of that air out, relieve some of that stress, so the balloon does not pop. In our bodies and nervous systems this is accomplished through soothing behaviors or activities. Some of these behaviors are healthier than others, but in the context of the balloon exploding, they all make sense in the moment. If our choice is to face what feels like an explosion inside of us or, say, use drugs to quell it, then in that moment the drugs are often a better choice. The problem lies when the effect of unhealthy coping mechanisms cause more damage than the physiological and psychological stressors that are reactions to perceived danger.
It’s often difficult for family and friends and the rest of the world to see the behaviors of “addicts,” behaviorally challenged, or people who struggle with mood disorders, as anything more than a moral issue. I’ve heard that discussion too often. What people don’t understand, they may despair of, or look for someone/something to blame or label. So those who don’t understand or know better may slot addictions and behaviors in a morality slot. They may also label people they don’t “get” as black sheep, the bad seed, the sociopath, or borderline. We are not our behaviors, and to wag our finger in the face of a child and repeatedly call him or her the bad kid does not do justice to the child, or quell the need for the behavior.
To help families understand the cycle of relapse, we created the Black Dot to describe this phenomenon. It illustrates unresolved trauma, and feelings surrounding it.
As noted in the diagram on the following page, the blackness is the very center of the deepest pain. In trauma treatment we slowly walk into the pain that we have been avoiding with whatever survival behavior that seemed to work initially. As you absorb the trauma stories and the artwork, perhaps you will understand and feel the fear of entering the pain of the Black Dot; avoidance at all costs seems to be the answer. However, enter we must to heal and have the life we deserve.
The Black Dot
We walk in slowly and feel some of the depth of feelings, but then we perceive too much fear, shame, guilt, sadness, nightmares, and more, plus controlling memories around the trauma. Most run from the pain which is the expected response, and most run to a soothing survival behavior to avoid the pain and it can be any of those behaviors surrounding the Black Dot. That is the relapse cycle: pain avoidance.
However, if we can partner with our client and their group and walk with them and support them in the center of the darkness most can and will walk into the pain, experience, truly experience what they have been avoiding, have sensory, cellular, visceral relief and discharge. This happens over a period of time with many and various tellings of the story, and culminates in rewriting their story. Perceptions shift and change, resilience and resources are built, and relapses in behaviors happen in treatment. Of course they do, and we should not discharge. Our clients are finding their way through the Black Dot, some kicking and screaming, some immersed in grief, because giving up their trauma identity can be a huge loss as well. Others charge in, ready to be rid of the chains that trauma has wrapped them in.
Please be aware that this is a long, exhaustive, and intense process. It can’t be rushed and is difficult to do within a fifty-five-minute outpatient format; not impossible, but difficult. By sharing the diagram of the Black Dot, family and friends often are able to recognize the behaviors—not right or wrong, good or bad—but survival strategies.
Soothing Behaviors
Following is a list of some soothing behaviors broken up into common unhealthy and healthy categories. It should be noted that any behavior used to excess could become unhealthy. All these behaviors are used in some way to activate or calm the nervous system, whatever the nervous system needs, to create a sense of relief. Even though these unhealthy coping strategies all work on some level, they are not the best way to deal with our reactivity even though initially they are very powerful.
Unhealthy Soothing Behaviors
Substance use: alcohol, drugs, any mood-altering substance. This is a common soothing behavior for many trauma survivors, especially for younger ones, and the reason so many survivors are also addicts.
Food: another coping mechanism found easily and early in life that may express itself as binge eating, bulimia, or anorexia. Binge eating is eating to soothe from the intake of the food; anorexia creates a feeling of control by not eating; and bulimia is a combination of both, along with the body reaction of purging the food. This is in no way saying that this is all that exists within or explains these disorders, just the way and reasons in which they are sometimes initiated.
Self-harm: cutting, burning, scratching, head slamming, bloodletting, and any number of self-harming behaviors. This may seem counterintuitive, but self-harm is used for different reasons in a way that impacts the trauma survivor psychologically and physiologically. Sometimes it’s used to calm the nervous system, and others harm themselves to excite the nervous system or “feel” something when they are numb.
Sex: sex can have both a physiological and psychological effect on us. This is often tied to sexual trauma, and, as with food, can be a bingeing or anorexic activity. Within the sexual realm are innumerable behaviors that are used to activate or numb, such as compulsive masturbation and viewing of pornography, prostitution and massage parlors, and the whole gamut of acting out sexually. Avoidance of sexual behaviors or sexuality can often be tied directly to trauma response, or used as a sense of control or avoidance.
Relationships: compulsive relationships or using another person to alter the way we feel. This is a very common coping mechanism for many people. Avoiding relationships can also be used as a form of control.
Work or achievement to excess: in an attempt to regulate our feelings of anxiety, we might focus our energy and attention on work or achievement. While this may seem healthy and is often admired or encouraged by others, in many instances this is done to the detriment of the rest of one’s life.
Truly any activity or substance used in excess can be harmful, having a detrimental effect on our bodies and our lives. While they may provide short-term relief, they can create greater long-term damage. Soothing behaviors must be balanced and used in a healthy manner in concert with therapy. Some healthier choices may include the following.
Healthy Soothing Behaviors
Yoga
Healthy and balanced exercise
Meditation
Breathing techniques
Therapeutic writing
Therapeutic use of art
Activities in nature such as gardening, hiking, biking
Movies
Music
Driving in the car
Taking a bath
Prayer
Twelve-step fellowship
Hobbies
Religion or faith-based activities
When it comes to traumatic response, soothing behaviors can be as individual as the responses. What regulates one person may be triggering to another—this is particularly true with music and movie choices—so the idea is to find what works for you and add as many of these tools as you can to your toolbox. When the balloon is starting to fill, use the healthy soothing coping mechanisms to let air out. Learning to be responsible for self-soothing and self-regulation is essential to trauma resolution and leading a healthy productive life.
The definition of self-injury (SI), self-harm (SH), or deliberate self-harm (DSH) is deliberate infliction of tissue damage, or alteration to oneself without suicidal intent. Although the terms self-injury or self-harm have been used to refer to infliction of harm to the body’s surface, the term self-harm may be used to include the harm inflicted on the body by those with eating disorders. Some scholars use more technical definitions related to specific aspects of this behavior. These acts may be aimed at relieving otherwise unbearable emotions, and/or sensations of unreality and numbness. Self-harm is listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) as a symptom of borderline personality disorder and depressive disorders. It’s sometimes associated with mental illness; a history of trauma and abuse, including emotional abuse, sexual abuse, and eating disorders; or mental traits such as low self-esteem or perfectionism. A statistical analysis is difficult, as many self-injurers conceal their scars.
The relationship between self-harm and suicide is a complex one, as self-harming behavior may be potentially life-threatening, with or without suicidal intent. However, attributing self-harmers as suicidal is, in the majority of cases, inaccurate. Non-fatal self-harm is common in young people worldwide, and, due to this prevalence, the term self-harm is increasingly used to denote any non-fatal acts of deliberate self-harm, irrespective of the intention.
I want to offer hope and describe our clients as courageous when the most overriding drive they have is for “relief” in all its many forms, relief from the unceasing pain that so many experience in such a visceral, cellular, and sensory way, with the body, mind, and spirit on constant overload.
I want to move from the language of mental illness and addictive disease to a more honest language that defines those behaviors as imperative, useful, lifesaving, and spirit-redeeming.
I want to emphasize “behaviors” as the survival tools that they are, and that behaviors can change when we feel safe, trusting, and no longer in fear for our lives.
I want to invite our field to recognize that dual diagnosis is a myth; that unless we all become competent in all these areas—mental health, substance addictions, process addictions, and trauma—we will always be performing a disservice. These elements always overlap and support and define each other. As clinicians, our expertise has to grow and broaden.
Consider a poem that was written by one of my clients. This poem could have been written by hundreds of clients over the years. Olivia’s poem has always touched my heart as it evokes the loss of innocence and safety, the soul wound, the moral injury that will always linger just below the surface. At thirteen, Olivia’s innocence was ripped from her. As she continues to heal, she finds freedom and strength, a way to soar that can never be taken from her.
In the Moment
I’m flying with broken wings
I can’t quite make it but I can fly a little
I’m flying with broken wings
It’s going to take time for them to heal
But until then
I’m flying with broken wings
When they are healed, I can soar the skies
And no one can take that freedom away from me
But for now
I’m flying with broken wings
*
Reflective Sketches
*
1) As you read about PTSD and moral injury, what were the thoughts, questions, and feelings that came up for you?
2) Identify any circumstances or events that you have taken responsibility for, felt guilty about, or felt shame for. Are you questioning the truth of that identity? Can you see that experience in anyone else in your life?
3) What would you need to be forgiven? And who or what should provide absolution?
4) We often have our own answers within. What is your inner voice telling you?
5) Has your “shininess” been tarnished?
6) Create three ways that you can begin to forgive yourself and begin to polish the brilliance and shininess that you were born with. It can be as simple as looking in the mirror and repeating positive affirmations, or finding pictures of yourself and recognizing that you were precious and just a little child who deserved more.
7) If you have children or young relatives, can you see their beauty and brilliance? Would you allow anyone to hurt them by thoughts, words, or deeds? Can you begin to embrace the shiny child that you were before the trauma messages changed your vision?
8) Choose just one change that you will make from today onward for yourself. Commit to that for one month, one day at a time.