MADIGAN ARMY MEDICAL CENTER, Joint Base Lewis-McChord, Wash. -- Madigan Army Medical Center's Warrior Transition Battalion hosted its first moral injury workshop and retreat in Letterman Auditorium and the Madigan Chapel on March 22.

"Moral injury doesn't happen to everyone. But, after 18 years of combat and non-stop deployments, we do have a lot of people dealing with moral injury," said Chaplain (Maj.) Jonathan Entrekin, the chaplain for the 42nd Military Police Brigade, as he spoke to the audience drawn from around Joint Base Lewis-McChord.

In defining moral injury, Entrekin explained that this is the transgression of morality -- or crossing the line of right and wrong. Everyone has a moral compass that is set within a moral community.

"We belong to these communities because we adopt those morals; if we don't, we aren't accepted in that community," said Entrekin.

Entrekin gave further definition from an article by Dr. Brett Litz entitled, "Moral injury and moral repair in war veterans: A preliminary model and intervention strategy," that was published in Clinical Psychology Review in 2009.

Litz said, "Moral injury is perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations."

Post-traumatic stress disorder is a diagnosis that has developed a fairly high degree of recognition and understanding. Entrekin pointed out that moral injury, however, is frequently lumped in with PTSD and not addressed effectively as the separate issue that it is.

Entrekin explained that one must look at what necessity is lost in each condition to understand the distinction.

Where PTSD is concerned, the main human need that is damaged is safety. A person with PTSD has been exposed to situations that put them on constant high alert, shattering that sense of safety.

With moral injury, though, it is trust that has been compromised, he explained further. Either because of their own actions or what they now know, they are not the same person they once were; they report feeling changed and often sullied.

The signs and symptoms can look similar to PTSD. Misconduct is common and a change in personality over time can be seen. There is an alienation from self, or as Entrekin described a patient's view of it, "I've done something I think is wrong and I don't know who I am anymore."

Even this separation from self is a form of isolation, which Entrekin ties to suicide risk.

"Every situation with suicide, and yes, I'm stating the absolute here, comes from isolation. Isolation is the real killer," said Entrekin.

Guilt and shame make the person feel transformed into someone they don't recognize. Anger and doubt, including doubting their concept of morality or the ultimate moral authority, pushes them to no longer want to be a part of their moral community as they now question its validity.

They become isolated because they know they have changed and yet others do not understand this and relate to them as their old self.

After describing these characteristics, Entrekin stressed that moral injury is not limited to combat-deployed Soldiers, or Soldiers at all. Anybody can, and likely does, have some form and degree of moral injury he asserted.

On the surface, moral injury treatment appears embedded in religious practice. Its treatment is entrusted to the Chaplain Corps and can certainly be religious in nature, if that is the moral community the patient needs to engage in order to achieve healing.

Entrekin made his approach clear from the outset. Healing moral injury requires neither a specific faith nor any religious faith at all, he said. It is based entirely on setting oneself right with their moral conviction and community. He stressed that he connects those who come to him with their own moral community and is careful to preface his own Christian frame of reference as he offers insights.

A useful element of treatment that can be both religious and entirely secular is ritual, he said.

"Rituals transform ordinary actions into emotionally-involved communication, about an actual event which has taken place, conveying present and future meaning," explained Entrekin.

Where Entrekin has used the medieval labyrinth in his treatment, another presenter shared her experiences in leading participants in the ritual of pilgrimage.

Dorothy Perkins is a retired Army colonel who is a trip leader for the Warriors to Lourdes Program Pilgrimage that takes active-duty service members, veterans and their families to France to experience a site where a young Catholic woman professed to see visions of the Virgin Mary.

Pilgrimage is itself another time-honored ritual. Perkins is heavily invested in the healing experience for those she leads. She has made special ceremonies and connections happen for her travelers.
She said she knows healing is individual. She described paying close attention to one particular Soldier, waiting for a clear indication from him that he was ready to talk about the experiences that lead to his injury. When it came, she had the resources ready to help him.

"Continue to listen to those little indicators; partner with behavioral health and get the needed expertise," she advised.

Reverend Michael Johnson, an ambassador for the REBOOT Combat Recovery Program, said he knows from experience that the resources for healing are not exactly robust.

Johnson was medically retired after 28 years in the Army -- years he confessed broke him physically and spiritually. After doing a lot of self-help work, he came to the realization that, "Anger, shame, guilt and low self-worth are the body's voice crying out, giving words to the pain."

When it looks as though a person is least interested in being with their community is when they need it the most.

"Moral injury must be brought forward into the community to be repaired. Transformation only comes through transaction," he said.

Johnson offered information on the resources to be found in the local community, the elements of spiritual healing and that his intention is to come alongside behavioral health to help the individual heal both psychologically and spiritually or morally.

The presentations were followed by an hour-long guided visualization in the chapel to give attendees a taste of one of the tools used in the healing process.

This workshop was designed to be an introduction to the basics of moral injury and how to guide patients towards healing. Chaplain (Capt.) Gabriel Bultz, the battalion chaplain for the WTB, said it was intended to bridge behavioral health and pastoral services and will in the future include more guided meditation work, walks around the pond and other practical elements of treatment.

If you believe you or someone you care about is struggling with moral injury, contact the chaplain service, behavioral health or talk with your primary care provider about effective ways for you to find healing.