It was a rite of passage. It was not a cure. It allowed me to be just a little bit happier. It probably saved my life. But it’s not a fairy-tale ending.
—Marine Staff Sergeant, two combat tours, former patient at the moral injury group, Naval Medical Center San Diego
The wars in Iraq and Afghanistan had been under way for some time before the mental health community was able to begin grappling seriously with the puzzle of moral injury that was plaguing new veterans like Brad Ruther and Darren Doss. But by 2005 the foundations were being laid for understanding moral injury, for separating it from PTSD. Bill Nash had returned from his tour in Iraq determined to find a better way to deal with combat stress. At the Boston VA Medical Center, Brett Litz was continuing a decade of work, trying to define the varieties of trauma that troops experienced in war and to gain insights into the mechanisms and treatment of these psychological injuries. Eventually they would collaborate on a new kind of therapy designed specifically for moral injury.
At the marine base at Camp Pendleton, meantime, an innovative form of treatment for moral injury was being pioneered by someone who was neither a psychiatrist nor a psychologist.
It was a kid who grew up in a blue-collar family outside Boston, the third of four children of Anna and Carmelo Castellana, a hardworking, hard-drinking World War II veteran. The future therapist was his son Michael, who had been relentlessly bullied in their working-class neighborhood for being smart and sensitive and gay, who had lived through deeply troubling trauma as a young man, who’d discovered that teaching teenagers and gays and lesbians to express themselves through drama could help them deal with their own personal difficulties, and who eventually, after doctoral-level training in psychotherapy, was hired as a therapist for the combat-hardened marines at Camp Pendleton.
Michael Castellana arrived there in 2005, determined to do something to ease the pain and anger of marines returning from combat. A woman staffer at Pendleton heard that Michael was coming. She thought, A gay man? They’ll eat him alive! Then she met Michael and thought, He’s perfect. Castellana had an intuitive grasp of what marines were feeling and knew from his treatment of other traumatized people how to draw them out and help them. He won the trust of the marines and within a year had written a manual for the treatment of what the Marine Corps called combat stress. In truth, it was a treatment for what would later be recognized as moral injury. After a couple of years working as a therapist at Pendleton, Castellana one day opened his office door to a marine he didn’t know. You know I’ve heard about you, the marine said. People are talking. Castellana said, Yeah? Oh yeah, the marine said. Are you ready for this? They call you the touchy-feely tough guy. You’re tough as nails, but you, like, love people. Castellana said, I’m good with that.
Castellana, in his late fifties, has wide penetrating eyes, a neat salt-and-pepper beard, and an open manner that invites easy and thoughtful conversation. He and I were talking over breakfast at an outdoor café in San Diego, enjoying the spring flowers blossoming in the cool early morning air. When he first got to Pendleton, Michael said, he didn’t find it easygoing. Marines did come see him and would want to talk in individual therapy sessions, but like Nik Rudolph at Camp Lejeune, many were reluctant to join the group sessions that Michael thought were more effective. Eventually he would persuade them to take part, and once they got used to being in group, they couldn’t stop talking. Some of what they had to say, the experiences they wanted to get off their chests, was jolting. “I used to tell my marines, I don’t scare easily. Which is a crock of shit, of course, but I would let them tell me anything,” Castellana told me. “I’ve heard the most heinous things that humans can do to other human beings. Stuff to make your toes curl. But in my capacity to love them and to see that, in an effort to do what is right, they sometimes do something so wrong—their goodness seems to be intact and I seem to be able to connect with that. If they were in my office, if they were talking to me, then they were capable of redemption.” As the waitress hovered, he broke off. “Two eggs over easy, please.” Over light, she corrected. “Right,” he said gently. “You turn them over and take them out of the pan.”
One key insight that struck Castellana was that the seeds of forgiveness would come not from him or any other outsider. They could only come from a marine’s peers. On that he diverged sharply from Chaplain Etter’s insistence on the primary role of a spiritual leader. But Castellana built the central role of peers into his model for twelve sessions of moral injury repair. Forgiveness was a critical piece of the therapy, he knew, but a lot of work would have to come first. Combat veterans who feel they have done or seen something awful are often afraid of being shamed or rejected by their peers. Worse, that they’d be made fun of. Those fears would have to be overcome, Michael saw. The opportunity for forgiveness, from the group and from the individual, would come late in the twelve sessions when a marine would feel safe and comfortable and could find the courage to speak of his trauma, to relate something awful he or she had seen or done, and the marine’s peers in the room would be ready to accept that without judgment.
I nodded as Michael was describing this moment. Somewhere I had heard the phrase “listening with validation.” I understood that to mean what I’ve often tried to do as a reporter: listening without judgment but accepting the weight of the person’s story. Listening to Nik Rudolph, for instance, talking about killing the child, I was tempted to say, Oh, don’t worry about it, you couldn’t help it, it was war, he was shooting at you. All true, of course. But as Nik was struggling toward forgiving himself, not a helpful response. He’d already rejected those flimsy excuses. Killing a child was just wrong; no way around that. As Bill Nash would say, no way to unring that bell. To validate Nik’s experience, to recognize it as something hard and real, the best approach was a phrase I’d adopted from the marines: Yeah, that was fucked up. Notice that it doesn’t affix blame. It doesn’t excuse, either. It makes room for other factors (The kid you shot is partly to blame; he was shooting at you!). It allows for acceptance and forgiveness.
In Castellana’s group, one staff sergeant kept warning that he had something, that it was coming, that he wanted to tell the story, and Castellana kept saying, Not now, not now, the time will come, and finally around the sixth session the time came and the staff sergeant talked about how he had tortured prisoners. It was bad. It was fucked up. He spoke with his head bowed, eyes to the ground. The group sat in silence. When the staff sergeant was finished, Castellana said to him, “You were so concerned about what people would think. Why don’t you take a moment and look into the eyes of all the other group members?” And he did that. “He was really trying,” Michael said. “A father of three. And I asked him, ‘What do you see?’ And he said, ‘Well, I didn’t see anyone look at me differently.’ He said, ‘I think I’m not the only one here with a story like this.’ Imagine the weight lifted off his shoulders.
“I’m getting shivers just telling you this,” Castellana said to me as our eggs arrived. His were over light.
Around the time that Castellana was engaging with marines at Camp Pendleton, Brett Litz, who is an energetic man with a close-cropped gray beard, a gravity-defying tangle of red hair, and a perpetual look of doubting skepticism, was bringing the cold eye of science to what had long been the muddled business of treating war trauma. From the outside, Litz seems an unlikely pioneer in wartime trauma. He didn’t grow up in a military family or even near a military community. He came of age in the 1970s in Sea Cliff, New York, a prosperous and picturesque village on Long Island Sound. He was drawn into the academic world at North Shore High School, working (and getting high) with teachers who encouraged rigorous intellectual discussions on a first-name basis. Excited by this kind of academic probing, Litz enrolled at nearby Stony Brook University, which happened to be a hotbed of an emerging form of psychotherapy called behavioral therapy.
Behavioral therapy was a sharp change from the Freudian idea that mental illness sprang from unresolved childhood trauma. It was Freud’s theory that lay behind the conviction held by many psychologists in World War I that anyone suffering from “shell shock” simply had unresolved childhood issues, and the soldier could be treated briefly and sent back into battle. That approach continued into the 1960s and 1970s, when psychologists began working around the theory that abnormal behavior wasn’t a left-over childhood problem after all. It was learned and could be unlearned, through a variety of different therapeutic models. Cognitive behavioral therapy and a variant, cognitive processing therapy (CPT), had the therapist and patient working together to articulate, understand, and challenge distorted and destructive thoughts (Something bad happened to me, therefore I must be a bad person) and to replace them with more positive self-concepts. Behavioral therapy was exciting because it promised a more immediate and practical problem-solving approach to mental distress. But what caught Litz’s skeptical eye were the dozens of scientific clinical trials that seemed to prove behavioral therapies to be effective.
Litz waded into this work with zeal. He trained as a psychologist in exposure therapy, a form of behavioral therapy in which patients are asked to repeat in detail their most traumatic experience. Unlike critical incident stress debriefing, which relies on one immediate session to share stories, exposure therapy centers on reexperiencing the trauma over and over to the point where it will lose its power, and the anxiety or dread produced by the experience will fade and become extinguished. The problem, Litz soon realized, was that when people were asked to recount a troubling or shameful episode, most of them shaded the truth. It was the same thing Castellana was encountering in his sessions with marines: when they were given an opportunity to talk about what was troubling them, they’d often pick something minor at first; the hard, black stuff would come out later when they’d had a chance to try out a story in group, and it didn’t blow up on them. For most people, “It’s what they are willing or able to tell you,” Litz said. “You have to do some detective work, and you can’t assume that what you’re being told is all there is to the story. Shame,” he said, “often gets in the way.”
That got him interested in a phenomenon called emotional numbing or social detachment, now considered a symptom of PTSD and moral injury, a way to bury unpleasant or traumatic emotions by simply avoiding contact with others. “It was very poorly defined. What the hell was it—depression, or something else?” Litz wondered. “I spent two or three years putting a scientific lens on it.” By that time, in 1987, he was working at the VA medical center in Boston, engaging with patients. But his real love was the research: figuring out and demonstrating not just what works but why. He found the VA “a great culture for innovation, a lot of creativity.”
So nobody objected when in the early 1990s he got interested in the mental health problems experienced by U.S. troops returning from peacekeeping operations in Somalia. He led a team that examined thirty-five hundred recently returned soldiers for signs of PTSD, which at the time was considered the overall explanation for every kind of war trauma. War trauma was thought to be caused solely by fear. Fear dysregulation, psychologists called it. They understood that military personnel exposed to peril often developed acute anxiety, insomnia or nightmares, a startle reflex, all of it caused by fear. You went into harm’s way, had a terrifying experience; you got PTSD. The VA knew how to diagnose PTSD and treat it. Litz wanted to know more (“What the hell was it?”), and in the course of the research project he found something that would drive decades of his work on moral injury: the rate of diagnosed PTSD among troops who’d served in Somalia was “small but significant.” That amount of trauma was understandable, given that the soldiers and marines sent to Somalia had been plunged into the midst of a bloody civil war in which Islamist extremist fighters, the forerunners of al-Qaeda and ISIS, were making their first murderous appearances. Litz and his colleagues found that about 8 percent of the U.S. troops had symptoms of PTSD.
But why? Fear alone couldn’t explain it. This had been a peacekeeping mission, and the rate of PTSD was below the contemporary estimates for Vietnam combat veterans (10 percent) and Gulf War veterans (14 percent).
The more Litz thought about it, the more he felt the explanation of PTSD and the therapies designed for it were too thin. Here was a puzzle: if PTSD was fear based as the psychiatry profession declared, if war trauma was caused by one’s reaction to a terrifying incident, why was it so prevalent among well-trained American troops engaged in a peacekeeping operation? After all, the military had done its best to inoculate its troops against fear. Service members were preselected for physical and mental acuity: low grades on physical fitness and intelligence tests disqualified many applicants from enlisting. Those who were accepted were relentlessly trained in grueling combat exercises and supported by close intimates who served together over time in small units. That was thanks to a deliberate shift in military personnel policy made in the early 1980s that bolstered unit cohesion by abandoning the Vietnam-era practice of moving soldiers around individually among units instead of keeping them together for years. The peer support that developed, together with the military’s effective small-unit leadership, ought to be enough to enable soldiers to recover from dangerous experiences, Litz thought. Then why were the peacekeepers showing up with symptoms of trauma?
In an eerily accurate preview of the wars in Iraq and Afghanistan, in findings published in 1996 he concluded that American troops in Somalia were disoriented and troubled by “ambiguous, inconsistent or unacceptable rules of engagement (ROE); lack of clarity about the goals of the mission itself; a civilian population of combatants; and inherently contradictory experiences of the mission as both humanitarian and dangerous.” Somalia, he wrote, seemed to be “the prototype of a new paradigm in military operations,” one that “may represent a unique class of potentially traumatizing experiences not sufficiently captured by traditional descriptors of war zone exposure.” In other words, the troops were reacting emotionally to morally difficult circumstances; their PTSD symptoms weren’t entirely driven by fear. And those circumstances, Litz felt certain, would appear again and again.
Something else began to bug Litz. The treatment offered by the VA for war trauma had come out of the civilian world, and specifically from therapies designed for people who had suffered a onetime trauma or victimization, such as rape. Tested exhaustively in clinical trials, these were known as evidence-based approaches: cognitive behavioral therapies, which Litz had mastered at Stony Brook, were effective in extinguishing the lingering fear in cases of rape, motorcycle accidents, and similar traumas. The label “evidence based” was a kind of marketing seal of approval, like the TV-ad phrase “laboratory tested!” So why were those same therapies less effective in clinical trials with veterans diagnosed with PTSD?
What Litz was learning from the veterans he was seeing at the Boston VA pointed toward part of the answer: the therapies weren’t wrong; the diagnoses were incorrect. Their distress wasn’t caused only by fear stemming from a life-threatening incident but also from emotionally and morally disturbing incidents in war. Often, Litz found, it was remorse, shame, and guilt from feeling they had failed in some way to act heroically in the face of peril.
Evidence-based therapies using cognitive behavioral techniques, Litz would later write, “do not sufficiently explain, predict, or address the needs of many service members and veterans who are exposed to diverse psychic injuries.” He could see the need for a new military-specific form of therapy that would take into account the unique culture and ethos of the military and the unique moral stressors that arise when men and women are sent into the kinds of frustrating, ambiguous conflicts he’d studied in the Somalia peacekeeping operation. Something that would enable combat veterans to voice their deepest concerns and to receive forgiveness.
While Brett Litz was puzzling over this, one of his young colleagues, Shira Maguen, was looking for clues in a slightly different direction, linking the moral injury Litz was documenting directly to killing. She found that her PTSD patients frequently mentioned killing as a cause of their distress, killing they had done in combat. Maguen was intrigued but hardly surprised. She had been born in Israel and was familiar with war. Both her parents served in the Israeli Defense Forces; her father had fought in the Yom Kippur War. After college in the United States, she worked with Litz at the Boston VA for four years, using CPT and similar therapies that sought to extinguish fear-based trauma. “But what I was seeing,” she told me, “was not so much of the fear-based response but struggles that were related to what they did and what we now think of as moral injury. Crossing certain boundaries, what they defined for themselves as their own moral values.” These were issues, she said, “not traditionally captured by treatments of evidence-based therapies.”
What was needed, she determined, was an additional specialized therapy that would address the shame, guilt, and feeling of self-contamination that she was seeing in her patients. “If someone is carrying around all those cognitions,” she said, “they can’t lead a successful life.”
Across the country, Michael Castellana had come to the same conclusion, that a new model of therapy for war trauma was needed. Michael wasn’t a Ph.D. psychologist. He did not have a medical degree in psychiatry. He had put himself through Brandeis University and earned a master’s degree in social work at Boston University. He was the first person in his family to go to college and wasn’t able to finally pay off his student loans until he was forty-four years old. He had done doctoral-level training in clinical and pastoral psychotherapy, but his deft touch in working with cases of trauma was intuitive and experiential. What connected him across the worlds of academic, scientific psychology and the gritty reality of people in trauma was his intense personal empathy. It’s as if he can see into your soul and understand it.
Over breakfast, he told me that he’d been working in private practice in San Diego when the terrorists struck on 9/11 and the United States lurched into war in Afghanistan and then Iraq. Michael thought, If this doesn’t end quickly, I know what’s going to happen. It didn’t end quickly. He got in touch with everyone he knew in the military, asking how he could get involved and eventually came across a job opening at Camp Pendleton for a trauma therapist. He was anxious, late for the interview, but he got the job.
I stopped him right there. You’re a gay guy with no military experience—and it will be years before gays can serve openly. What made you think you could just walk in there and deal with marines’ trauma?
He grinned. Approaching Pendleton, “I was really kind of overwhelmed,” he admitted. “But I knew trauma.” He meant that in a personal way. It turned out to be a long story that unfolded as we dawdled over the remains of our breakfast, and it took us back to Watertown, Massachusetts, where Michael’s father, Carmelo, had a barbershop and his mother, Anna, who loved opera and sang in clubs when she was younger, worked in a car-parts factory and sang when she got home at night. In 1951 Anna discovered a tumor in her neck, and doctors cut it out, but the operation left one of her vocal cords paralyzed. She could never sing again. But she kept as happy a home for her four kids as she could, what with money worries and long hours at the factory and Carmelo’s heavy drinking.
After Michael was out of college and working as a therapist, she got sick again, and Michael, then twenty-four, moved home to take care of her, living in the basement. They were close, really close. When he had gotten a job in California, they had driven together across the country. She used to tell him, smiling, Michael, you have good taste in men. “She was a wonderful person,” Michael told me. “Wonderful.”
One night he heard his mother cough in the upstairs bathroom. “It was like someone stuck a knife in my chest. I could feel this presence. Like, my mother needs me. I threw my toothbrush down and ran upstairs, and my father was standing there dazed, white as a ghost, in the kitchen trying to buckle his pants, and he said, ‘We have to get to the hospital now!’ I ran into the bathroom where my mother was.” He paused. “It was like someone had slaughtered a pig. She had a carotid blowout,” a rupture of the main artery in her neck, which carries blood from the heart to the brain. She was dying.
Michael bowed his head as he remembered the scene. Birds chirped from a nearby bush, and the waitress collected our plates. It was a few moments before he could go on.
The cops arrived at the Castellana house, carrying a useless little first-aid kit. Michael is holding his mother in his arms, blood all over, pleading with the cops, “Just get us to the hospital,” and outside there is no ambulance, only the squad car, so they all cram inside. Carmelo, still somewhat drunk, trying to get the driver in a choke hold, demanding they be taken to Mass General. “But we’re racing to Waltham Hospital, it’s closer, and my mother is kind of kicking my father and I’m trying to push him down and we’re barreling up Main Street and it’s like two a.m. and raining.”
And from a side street, a girl in a station wagon jumps a red light. She sees the police cruiser bearing down on her and freezes. A second later, the collision. “We T-bone her, I think that is the right word. Push her car sixty feet up the road. I watch this in slow motion. It’s the first and only time I have had an out-of-body experience, because I’m standing holding my mother in the rain and there is blood all over me and I see it from up above and behind and I see the flashing light of the gumball machine from the police cruiser that’s knocked off into the street… and this ruffian-looking kid in a leather jacket drives by and says ‘Man! You need some help?’ Hah! And I say, ‘Can you get us to the hospital?’ And the next day the cops said to me, ‘How did you open the car door? Everything was crushed.’ And I said, ‘I don’t know, I just… had to do it.’” Anna had broken her back in the crash. She lived on for a while. But the story wasn’t quite done. “When we got to the hospital I got her to the emergency ward and she looked up at me and she said, ‘How did you know I called you? I never said a word!’” In the telling now, at breakfast in sunny San Diego, Michael’s eyes filled, and he bent his head and whispered, “I heard you, Mama.”
Michael Castellana knew trauma.
At Pendleton, Michael worked for a year getting more and more frustrated with the existing treatment models, and in 2006 he was asked to join the Deployment Health Center and given free rein to work with marines returning from combat. It was exhilarating; he felt as if he’d been preparing all his life for this. One weekend he sat down and wrote a detailed curriculum for a brief six-week twelve-session group treatment model, designed to help marines relax in a safe environment and begin to understand their trauma, to learn some coping strategies, and, through the kind of exposure therapy that Brett Litz was studying in Boston, to begin sharing their trauma memories in a validating group. One session was devoted to a discussion about aggression; what happens when marines kill; the “addictive qualities of adrenaline surges”; and how different life is at home, given their experience with the weapons and authorized force and aggression they enjoyed in combat. And, finally, the concept of redemption. In his introduction, Michael wrote a caution to therapists who would follow his model:
The experts in the room are the ones who are there to do the talking, the sharing. We, the therapists, must listen. We are there to insure that the boundaries are kept clear and honored at all costs. We can help the group members to moderate their pain, monitor their progress, and to pace their journey so that they do not falter and lose face. Preserving their integrity is critical. These are remarkable, courageous men and women. We should laugh with them, grieve with them, and, most of all, empathize and inject a human perspective on the terrible experiences these service members have endured. We must bear with them, the distressing and challenging events they have lived through, and accompany them as they make their way to a new, fuller understanding and appreciation of their role in war and as fellow human beings in the world.
It was a sharp break from past therapies: healing would come not from the work done by patient and therapist but would come, in a setting created and monitored by the therapist, through forgiveness from one’s peers.
Whenever Michael had a new marine coming in for therapy, he had a ritual. He’d hand the marine two of his business cards. “One card is for you. Put it in your wallet, and if you need to cancel, call me. The other one, put in your pocket because I know damn well you know someone else that needs to be here,” Michael said. “People would come and say to me, ‘My buddy gave me your card.’ I’ve had people come back and ask for more cards; they’d given all theirs away. And so I built a practice on my credibility. Marines are tribal,” Michael told me. “And if you fuck up, it’s over. Because word spreads. But conversely when you help someone, it lasts a lifetime.”
Michael also had learned techniques to help morally injured marines understand that they alone don’t have to bear all the responsibility for what happened. One method I found easy to understand can be done in individual counseling. As Michael explained it, he would have the patient list and assign a percentage of responsibility to every person or factor that played a role in the injuring incident—say, if a marine had killed a child. The marine might assign himself 20 percent. The kid shooting at him, 15 percent. The Taliban who armed the kid and told him to shoot, 20 percent. God, maybe 30 percent. And so on. The idea is to help the patient see, even while acknowledging his own role, that he doesn’t have to bear 100 percent of the responsibility. Life can go on.
One day a marine sergeant came to see Castellana. He admitted he didn’t want to come, but his buddy, a guy Michael had treated, had insisted. This sergeant was a tough guy. Hard. His marriage was falling apart. He was angry, punching holes in the walls. When he got into the office, Michael said, Take off your blouse. The sergeant blinked, but he stood up and stripped off his uniform shirt and sat back down in his olive-green T-shirt. And they went at it. It took five individual therapy sessions. The sergeant was a squad leader, and the squad had been under attack by insurgents, including two kids, eleven and fourteen, and one of the kids shot at the marine squad, and the sergeant returned fire and killed them both. It was what the military considers a “good kill.” Back home, the sergeant had an eleven-year-old brother, like the boy he’d killed. His guilt was enormous. “He couldn’t look at his father,” Michael said.
In telling the story, Michael had to raise his voice over the raucous laughter of a trio of college women at the next table. “That was one of his chief complaints when he came in. Didn’t want his father to see him. So in the course of my treatment of him he was able not only to confess his ‘sin,’ and have me still love him, but to hear, as he grieved, how sad he was that the [Iraqi] adults in that situation had made the weapons available to those kids or poisoned them in some way and put them in this untenable situation and that as a marine his job was to ensure the safety of his marines, and he did that. But the cost was a personal one, and he couldn’t face his father because in a sense he felt like he had just slaughtered his baby brother.” Michael helped the sergeant understand that his pulling the trigger was only a small part in the tragedy; that those who armed the kids were also culpable, that those who set up the ambush were at fault as well. That it was a bad thing that had happened, but the sergeant needn’t shoulder all the blame and guilt; he could forgive himself. All this took time.
“Well, that man had one of the most remarkable turnarounds. He went home and he hugged his father and he told his father what had happened and he cried and his father cried and said, ‘Oh thank God I have my son back!’ Is that not the most beautiful story in the world? That he was able to see that there was no right answer? And that no matter what decision he made, it would have consequences. But his heart was pure, and if I saw him today I would love him just as much… A remarkable man.”
When word began to circulate about Michael’s trauma model, he was asked to travel around the Marine Corps to talk to groups of marines about trauma and moral injury and to brief other therapists. Soon his model was widely in use. One day at Pendleton, Michael’s phone rang. As Michael later remembered it, a voice demanded, “Who the hell are you? I read your model. How do you know all this?” Before Michael could answer, the caller said, “Would you be willing to train people across the country on this? Oh yeah—this is Bill Nash.”
Nash, the navy captain and combat psychologist, was working on a new concept with Brett Litz. The idea was to modify the previous generations of exposure therapy and cognitive behavioral therapy and construct a new model specifically designed for moral injury in active-duty service members. The demands of the war meant they didn’t have much time to work with individuals. The marines and soldiers who needed help needed it fast because they all were on schedule to deploy again. And anyway, Litz and Nash knew that the goal of actually healing a moral injury was unrealistic; what they were aiming for instead was equipping morally injured service members with the knowledge and skills for a lifetime of posttraumatic growth.
Working together, and aided by a half-dozen psychologists who had studied under Litz, they came up with a new definition of “moral injury”:
The lasting psychological, biological, spiritual, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.
One key insight underlay their new approach. Cognitive behavioral therapy and cognitive processing therapy sought to help the patient correct distorted thoughts and beliefs. Litz and Nash knew that the thoughts and beliefs held by combat soldiers and marines about their transgressions might be painful but weren’t necessarily distorted. Nik Rudolph knew he had killed a child. What needed attention was not distorted beliefs about the act of transgression but the shame, guilt, and anger of having violated your own moral code, one you share with your peers and family. Michael Castellana’s sergeant couldn’t face his father because he felt he had betrayed his father’s moral values and his own. But Litz and Nash understood, as did Castellana, that if service members felt guilt or shame or sorrow or anger, it meant they possessed an intact set of moral values. And they could be listened to and understood and forgiven and eventually healed within a safe and loving community.
For morally injured combat veterans who are earnestly seeking care, they wrote in a 2009 article sketching out their ideas, “forgiveness and repair is possible in all cases.” It would require sharing the traumatic experience with a group of peers, the method Castellana was implementing at Pendleton, then guiding the patient toward self-forgiveness and moving forward. The model Litz and Nash had in mind was intended not to complete a healing process but to enable patients to get clear about the event that caused their moral injury and to get the skills and resources they would need for a lifelong process of forgiveness and hopefulness. They called this approach adaptive disclosure.
“In my community there’s been this kind of assumption of the equipotentiality of trauma,” Litz told me. He meant treating all trauma as the same thing. “Motor accident survivors, one therapy works for them, so let’s apply that to service members and veterans. And of course if you just spend time being curious and learn what wars mean for combatants, you can’t help but wonder, What are we missing?” Coming up with something new was the obvious next step. “For me,” Litz said, “it was a fucking no-brainer.”
As part of their work, Nash developed a moral injury events scale to screen veterans for moral injury and to measure the extent and intensity of the wound. It asks for “never,” “seldom,” “sometimes,” or “often” responses to statements such as:
—I saw things that were morally wrong.
—I am troubled by having witnessed others’ immoral acts.
—I acted in ways that violated my own moral code or values.
—I am troubled by having acted in ways that violated my own morals or values.
—I feel betrayed by leaders I once trusted.
—I am troubled because I violated my morals by failing to do something I should have done.
As in Michael Castellana’s therapeutic model, the Litz-Nash adaptive disclosure approach first establishes a warm, supportive environment in which a marine who is expecting to be condemned for his or her transgression finds instead acceptance and support. Subsequent sessions reflect the idea of behavior extinction, with the therapist encouraging the marine to relate his transgression over and over until it loses its potency. It is helpful to have the patient close his or her eyes during this session, Litz and Nash note. But the goal is to create “a raw and emotional reliving and recounting” to break through whatever avoidance strategies the marine has put in place.
The retelling is repeated often, not to force an extinction of the painful memory but to begin to break down the expectation of shame and rejection. Eventually the therapist introduces the patient to positive “corrective” judgments about himself, and that is followed by sessions in which the patient is asked to imagine himself as a benevolent figure—a priest or senior officer—giving advice and support to a morally injured service member. This encourages the patient to articulate ideas about the capacity to do good, to engage in service, and to accept forgiveness from self and from peers. Finally, the patient begins to “make amends” with actual community service, not to try to offer reparations for past behavior but to reconnect with his positive values.
Further sessions teach the patient to carefully seek out positive and healing relationships beyond the therapy room. “Because many people do not know what to say about such things [the “toe-curling” stories Castellana has heard] and their reactions may be difficult to predict or interpret, guidance will be needed,” Litz and Nash warn. The therapy ends with extended conversations with the therapist about the lessons the patient can take on into life. Combat veterans with serious trauma and moral injury should be warned that “there will be challenging times ahead.”
In 2009 a group of psychologists working under the direction of Litz and Nash tested out the ideas of adaptive disclosure in six sessions with groups of marines and navy corpsmen recently returned from war and given the umbrella diagnosis of PTSD (the military has no diagnosis of moral injury, then or now). Among the researchers was Amy Amidon, a navy psychologist now working at the Naval Medical Center San Diego. The results were encouraging: the marines reported sharp reductions in the symptoms of moral injury: depression and negative views of themselves.
“We’re in a period of discovery,” Brett Litz told me on the phone one day. We were talking about next steps, and he was excited—“stunned” was the word he used—that the Defense Department was looking to award research money for work on moral injury repair. Litz had written a long and dense project proposal for a randomized controlled trial of adaptive disclosure for moral injury, one that would extend the therapy from six to twelve sessions.
Their proposed treatment would include a block of therapy specifically related to the moral injury of killing, based on the work that Shira Maguen was doing with her patients in San Francisco, in a program of six to eight sessions she calls “impact of killing” therapy. She explores with patients the emotional and physiological impacts of killing, then deals directly with self-forgiveness. Many veterans are resistant, believing that to forgive is dishonorable, dismissing a wrong they had committed. Eventually they are asked to write a letter to the person they killed, or to their younger self, explaining what they now understand about killing that they did not at an earlier time. “Part of self-forgiveness is understanding the context in which this happened, usually a situation where you are constantly making life-and-death decisions quickly without having all the information,” she said.
In 2012, Amy Amidon and Michael Castellana began piecing together all these various strands: the early work Castellana had done, the understanding of PTSD as distinct from the emotions of loss, guilt, and shame that are moral injury, and the new techniques of adaptive disclosure. They started working with patients who had been admitted to a PTSD treatment program at the San Diego Naval Hospital. In a ten-week program they called the Moral Injury and Moral Repair Group, patients learned to talk through their experiences with the group; they were directed to write a letter to themselves asking for forgiveness and were assigned to work in community service projects as a way of rediscovering their altruistic values.
“The healing mechanism of adaptive disclosure is owning your story—‘I’ve done some bad things’—and having people hear that and accept you,” Amidon told me one sunny afternoon as we talked in a courtyard of the hospital. “In the first week we introduce the idea of moral repair, the idea of doing things that in your heart you know are good and kind and bring you closer to the person you want to be.”
Disillusionment with the war is a major emotion that marines bring into the sessions: Why did we sacrifice so much, seeing buddies getting hurt and killed? Why did we do so much killing, only to see now that things in Iraq and Afghanistan are actually much worse? “Helping them make their own story to accommodate that—the idea that ‘Why am I doing this? What is the point if the world is an evil place?’ When you have to do something horrible, the difficulty is making any meaning out of it,” Amidon said. “Faith comes up in every session. ‘Why did God let this happen?’” She and her small staff do what they can in ten weeks, but it’s discouraging, she allowed. “I know the military has to create aggressive, antisocial, callous people, and the younger ones have this attitude that they’re going on one deployment and will come back the same person that left—but they won’t. Should we harden them?” she asked, repeating a question I had asked. “No, we should not! But we should be doing a better job of mentally preparing them for things like kids shooting at them and the woman with the bomb under her burka. That’s something the military misses in preparing them for war: ‘Why am I doing this?’”
The San Diego program is the only government initiative I could find that specifically addresses moral injury. There is nothing like it in all of the Defense Department’s medical facilities or at the VA, beyond the kinds of research that Shira Maguen and a few others are doing and some individual VA therapists who provide moral injury therapy. In fact, the world of those working with war-related moral injury is exceedingly small. Many of the published research on moral injury, for instance, lists the same people: Bill Nash and Brett Litz; Amy Amidon; Matt Gray of the University of Wyoming; NYU clinical psychologist Maria Steenkamp; Matthew Friedman of the VA’s National Center for PTSD; Richard Westphal, a former navy psychiatric nurse; and a few others. “It’s only us,” Litz told me. It’s a small world.”
In December 2014, the Department of Veterans Affairs signed a $16 million contract with IBM to install software at the VA’s data center in Austin, Texas, that the VA said would assist its doctors and therapists confused about how to treat patients diagnosed with PTSD. VA staff can plug in clinical data and electronic medical records, and the computer will spit out the appropriate treatment plan.
Despite this step toward the mechanization of war trauma therapy, I was impressed that even the small group of researchers was doing such innovative work on healing strategies for moral injury and mildly pleased that the VA and even the Pentagon were willing to fund research and clinical trials of the most promising approaches.
Still, I couldn’t help noticing an almost-complete disconnect between the enthusiasm of researchers like Brett Litz and Bill Nash and the many soldiers and marines I have talked to who came back after their combat tours and got no help whatsoever. One who did get help was Darren Doss, the marine from Charlie One-Six. In the spring of 2015, several months before I took him to lunch in Schenectady, Doss was arrested after a traffic altercation; in court he was offered a choice: jail or the VA’s PTSD clinic. He chose the latter. “I know a ton of dudes who should be here,” he told me at the time. “The reason they aren’t is—pride.”
I related this to Bill Nash one day, saying that it seemed to me that, despite all the research being done, not much of it was reaching the people who needed it the most. And something else that had been nagging at me: some people I knew, like Nik Rudolph and Stephen Canty and Stacy Pearsall, came back from war with deep moral injuries, and they seemed to be doing okay, perhaps healing slowly and perhaps just stuffing all that pain deep down inside. Canty said once that he tries to “distance” himself from the war. “I meditate, do yoga, to try to find peace with what happened in the war and who I am as a human being. I try not to be defined by that four-year period in my life and the fifteen months I spent in Afghanistan,” he said. “I can’t let that guilt consume me.”
It occurred to me, though, that even guys like Canty who seem to be doing okay would benefit from the best healing techniques that the mental health professions have learned about moral injury since 2001. But there appeared to be no connection between therapists and veterans to enable that to happen.
Nash sighed deeply. “It’s more than that, it’s something else,” he said. “We don’t have good treatments. We simply don’t.”
We’d met on a summer Sunday at an Asian restaurant in McLean, Virginia, and were waiting for his Mongolian beef and fried rice. Nash had just read a disturbing paper by Brett Litz and his colleague Maria Steenkamp. They had studied thirty-six major clinical trials of therapy for PTSD among active-duty troops and veterans, conducted between 1980 and 2015. They concluded that the most widely used therapies for PTSD—cognitive processing therapy and prolonged exposure (PE)—were only marginally effective. Their paper, published in the Journal of the American Medical Association (JAMA) in the summer of 2015, reported that “between one-third and one-half of patients receiving CPT or prolonged exposure did not demonstrate clinically meaningful symptom change.” Two-thirds of those receiving therapy still had symptoms of PTSD afterward. Contrary to earlier assurances of its effectiveness, prolonged exposure therapy tested in one large clinical trial “did not lead to meaningful PTSD symptom reduction,” they reported. In other cases, alternative therapies such as acupuncture or “healing touch,” which involves tapping specific points on the body while being guided through positive imagery, were just as effective.
I found this outrageous: the only therapies widely available from the United States government for combat veterans were ineffective. We sent people into war, and when they came home with moral injury, either they were ignored, or they were diagnosed with PTSD and given therapy that didn’t help. How could this happen?
The VA had officially endorsed both CPT and PE for treatment of PTSD back in 2008, based largely on studies of traumatized civilians, suggesting these therapies were effective. But they weren’t. Why? Perhaps, Litz and Steenkamp wrote, because war trauma is fundamentally unlike civilian trauma. Among those differences, they noted, were “the extended, repeated and intense nature of deployment trauma, and the fact that service members are exposed not only to life threats but to traumatic losses and morally compromising experiences that may require different treatment approaches.” They also noted that veterans dropped out of the therapy sessions at a higher rate than civilians.
Bill Nash also found all this eye-opening. “So with no treatment at all, some people are going to get better; some will stay the same; some will get worse,” he concluded. Those who got therapy fared about the same.
Nash paused to tuck hungrily into his beef, then went on. “What I look at to make sense of all this is, for those who get better, what is the effect size of the treatment? How much better do they get?” Effect size, he explained, is measured statistically by how far the results of a clinical trial deviate from the expected outcome, expressed as a standard deviation. The mean result might be, for instance, a control group that got no therapy, and a good result would be to achieve several standard deviations beyond that mean. “So an effect size of 1.0 means you have lowered the mean by exactly one standard deviation,” Nash said. “So 1.0 is really a small change. In the rest of medicine that would be considered failure. In the rest of medicine, you would not spend money on blood pressure medicine if in a population it lowered blood pressure by 1.0 standard deviations. Right?
“So the effect sizes for cognitive behavioral therapies, prolonged exposure, cognitive processing therapy, the ones that are most studied, in rape populations is about 1.3. And in combat veterans 1.0.” In the 2011 pilot study that Litz and Nash did using adaptive disclosure, “we had a 1.3, you know, which is better than 1.0, but how much better do we make the world? And then how much better is that than they would have gotten if we had done yoga or taken them fishing or horseback riding or… anything else in the world? It’s not compelling!”
And the risk of adverse outcomes is not known, Nash said. Prolonged exposure therapy can cause people to react violently, for instance, but there is no data on adverse outcomes for exposure therapy. “Over the years, working in inpatient units in psychiatry I have had many people who just lost it, gone crazy in exposure treatment for some trauma,” he said. “People know this at a gut level, or they hear of someone who had a bad experience. But what the rates are we have no freakin’ idea—we’ve never looked!”
There’s also a shortage of data, of understanding, about people who get better naturally, without treatment: “What are the predictors of getting better? Was it a spouse that could tolerate hearing the stories? These are the anecdotes that I hear all the time, guys say, ‘What saved my life was my wife hearing all the things that I did and telling me I love you anyway.’ And convincing them that they deserve to be loved. How many [got better] because they found God and forgiveness in church? How many because of peer support? How much of it was because they just did the things we all do to heal from moral injuries? I mean moral injuries have been around for as long as humans, right? What are the cultural ways of responding to that? You make amends? You seek amends. You try, if you have created evil, to create good!”
Nash paused as our server cleared away the plates. While adaptive disclosure and Maguen’s impact of killing therapy hold great promise, he said he thought the ultimate answers may lie elsewhere. “You have these treatments that are really not hugely better than nothing at all—and because of the side effects, there’s a chance they might make you worse.” For combat veterans who are badly broken, he added, “you do need mental health intervention to get them to sleep, to reduce the arousal level, manage suicide risk. But if you ask my totally shoot-from-the-hip opinion, I don’t think psychotherapists will ever be the solution for moral injury.”
Dr. Harold Kudler, the VA’s chief mental health consultant, sighed deeply when I called to ask him about all this. “Science tells us that prolonged exposure and cognitive processing therapy are treatments that work for PTSD,” he said, and added quickly, “when they are the right treatment for that person. What we’re less good at is deciding who’s the right person for which type of treatment. It’s not the therapy that’s wrong; it’s the goodness of the fit. I think the VA has a lot of work to do, and it’ll take a lot of years to do it well, to establish a sound method of determining the goodness of fit for any of our therapies. We need science behind that.” When I asked if that kind of research is under way, he sighed again. “Unfortunately, many people are so invested in their models that they have trouble stepping back to also consider the individual they are working with.”
None of these therapies, he added, is designed to fit moral injury. “I do think we don’t consider the moral injury aspect of this as much as we could or should. Some would argue that it’s not the place of clinical people, that we’re not chaplains or oracles. That’s an unsatisfactory answer in the twenty-first century. It’s in our province to do something about it, or at least to recognize it and have an approach to it.”
That confirmed a conviction that had been growing since I began studying moral injury: true healing of veterans with war-related moral injuries will only come from community, however we and they define community—peers, neighborhoods, faith congregations, service organizations, individuals.
That means it’s up to us.