Well: War Wounds That Time Alone Can’t Heal

Video

“Almost Sunrise”

In a clip from «Almost Sunrise,» Katinka Hooyer, a medical anthropologist and postdoctoral research fellow in Family and Community Medicine at the Medical College of Wisconsin, talks about the meaning of love and feeling moral pain.

By THOUGHTFUL ROBOT PRODUCTIONS on Publish Date June 5, 2016.

No doubt in the course of your life, you did something, or failed to do something, that left you feeling guilty or ashamed. What if that something was in such violation of your moral compass that you felt unable to forgive yourself, undeserving of happiness, perhaps even unfit to live?

That is the fate of an untold number of servicemen and women who served in Iraq, Afghanistan, Vietnam and other wars. Many participated in, witnessed or were unable to help in the face of atrocities, from failing to aid an injured person to killing a child, by accident or in self-defense.

For some veterans, this leaves emotional wounds that time refuses to heal. It radically changes them and how they deal with the world. It has a name: moral injury. Unlike a better known casualty of war, post-traumatic stress disorder, or PTSD, moral injury is not yet a recognized psychiatric diagnosis, although the harm it inflicts is as bad if not worse.

The problem is highlighted in a new documentary called “Almost Sunrise,” which will be shown next weekend at the Human Rights Watch Film Festival in New York and on June 23 and 24 at AFI Docs in Washington, D.C. The film depicts the emotional agony and self-destructive aftermath of moral injury and follows two sufferers along a path that alleviates their psychic distress and offers hope for eventual recovery.

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The new documentary “Almost Sunrise” follows Tom Voss and Anthony Anderson, two troubled Iraq war veterans, walking from Milwaukee to Los Angeles.Credit Thoughtful Robot Productions

Therapists both within and outside the Department of Veterans Affairs increasingly recognize moral injury as the reason so many returning vets are self-destructive and are not helped, or only partly helped, by established treatments for PTSD.

Moral injury has some of the symptoms of PTSD, especially anger, depression, anxiety, nightmares, insomnia and self-medication with drugs or alcohol. And it may benefit from some of the same treatments. But moral injury has an added burden of guilt, grief, shame, regret, sorrow and alienation that requires a very different approach to reach the core of a sufferer’s psyche.

Unlike the soldiers who were drafted to serve in Vietnam, the members of the armed forces today chose to enlist. Those deployed to Iraq thought at first they were fighting to bring democracy to the country, then were told later it was to win hearts and minds. But to many of those in battle, the real effect was “to terrorize people,” as one veteran says in the film. Another said, “That’s not what we signed up for.”

That war can be morally compromising is not a new idea and has been true in every war. But the therapeutic community is only now becoming aware of the dimensions of moral injury and how it can be treated.

Father Thomas Keating, a founding member of Contemplative Outreach, says in the film, “Antidepressants don’t reach the depth of what these men are feeling,” that they did something terribly wrong and don’t know if they can be forgiven.

The first challenge, though, is to get emotionally damaged veterans to acknowledge their hidden agony and seek professional help instead of trying to suppress it, often by engaging in self-destructive behaviors.

“A lot of vets won’t seek help because what’s haunting them are not heroic acts, or they were betrayed, or they can’t live with themselves because they made a mistake,” said Brett Litz, a mental health specialist with the V.A. Boston Healthcare System and a leading expert on moral injury.

The second challenge is to win their trust, to reassure them that they will not be judged and are deserving of forgiveness.

Therapists who study and treat moral injury have found that no amount of medication can relieve the pain of trying to live with an unbearable moral burden. They say those suffering from moral injury contribute significantly to the horrific toll of suicide among returning vets — estimated as high as 18 to 22 a day in the United States, more than the number lost in combat.

The film features two very troubled veterans of the war in Iraq, Tom Voss and Anthony Anderson, who decide to walk from Milwaukee to Los Angeles — 2,700 miles taking 155 days — to help them heal from the combat experiences that haunt them and threaten to destroy their most valued relationships. Six years after returning from his second deployment in Iraq, Mr. Voss said of his mental state before taking the cross-country trek, “If anything, it’s worse now.”

Along the way, the two men raise awareness of the unrelenting pain of moral injury many vets face and encourage them to seek treatment. Mr. Voss and Mr. Anderson were helped by a number of counselors and treatments, including a Native American spiritual healer and a meditative technique called power breathing. They also found communing with nature to be restorative, enabling them to again recognize beauty in the world.

Shira Maguen, a research psychologist and clinician at the San Francisco V.A. Medical Center, who studies and treats vets suffering from moral injury, said, “We have a big focus on self-forgiveness. We have them write a letter to the person they killed or to a younger version of themselves. We focus on making amends, planning for their future and moving forward,” especially important since many think they have no future.

Dr. Maguen, who studied how killing during combat affects suicidal ideation in returning vets, found that “those who had killed were at much higher risk of suicide,” even when controlling for factors like PTSD, depression and alcohol and drug abuse. She said in an interview that decades after the Vietnam War, “there was still an impact on veterans who killed enemy combatants, and an even stronger effect on those who killed women and children.”

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Tom Voss’ journey took 155 days, spanning 2,700 miles.Credit Courtesy of Thoughtful Robot Productions

To overcome veterans’ reluctance to seek help for moral injury, Dr. Maguen incorporates mental health care into routine clinical visits.

In Boston, Dr. Litz and colleagues are testing a therapeutic approach called adaptive disclosure, a technique akin to confession. With eyes closed, the vets are asked to verbally share vivid details of their trauma with an imagined compassionate person who loves them, then imagine how that person would respond. The therapist guides the conversation along a path toward healing.

“Disclosing, sharing, confessing is fundamental to repair,” Dr. Litz said. “In doing so, the vets learn that what happened to them can be tolerated, they’re not rejected.” They are also encouraged to “engage in the world in a way that is repairing — for example, by helping children or writing letters.” The goal is to find forgiveness within themselves or from others.

One fact that all agree on: The process is a lengthy one. As Mr. Voss said, “I knew after the walk I still had a long road of healing ahead of me.” Now, however, he has some useful tools and he shares them freely.

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Personal Health: Parenting Advice From ‘America’s Worst Mom’

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Credit Joyce Hesselberth

Lenore Skenazy, a New York City mother of two, earned the sobriquet “America’s Worst Mom” after reporting in a newspaper column that she had allowed her younger son, then 9, to ride the subway alone.

The damning criticism she endured, including a threat of arrest for child endangerment, intensified her desire to encourage anxious parents to give their children the freedom they need to develop the self-confidence and resilience to cope effectively with life’s many challenges.

One result was the publication in 2009 of her book “Free Range Kids: How to Raise Safe, Self-Reliant Children (Without Going Nuts With Worry).” A second result is the Free Range Kids Project and a 13-part series, starting Thursday on Discovery Life Channel, called “World’s Worst Mom.” In it, Ms. Skenazy intervenes to rescue bubble-wrapped kids from their overprotective parents by guiding the children safely through a sequence of once-forbidden activities and showing their anxious parents how well the children perform and how proud they are of what they accomplished.

The term “helicopter parents” applies to far more than those who hover relentlessly over their children’s academic and musical development. As depicted in the first episode of the series, it applies to 10-year-old Sam’s very loving mother who wouldn’t let him ride a bike (“she’s afraid I’ll fall and get hurt”), cut up his own meat (“Mom thinks I’ll cut my fingers off”), or play “rough sports” like skating. The plea from a stressed-out, thwarted Sam: “I just want to do things by myself.”

In an interview, Ms. Skenazy said, “Having been brainwashed by all the stories we hear, there’s a prevailing fear that any time you’re not directly supervising your child, you’re putting the child in danger.” The widespread publicity now given to crimes has created an exaggerated fear of the dangers children face if left to navigate and play on their own.

Yet, according to Peter Gray, a research psychologist at Boston College, “the actual rate of strangers abducting or molesting children is very small. It’s more likely to happen at the hands of a relative or family friend. The statistics show no increase in childhood dangers. If anything, there’s been a decrease.”

Experts say there is no more crime against children by strangers today — and probably significantly less — than when I was growing up in the 1940s and ’50s, a time when I walked to school alone and played outdoors with friends unsupervised by adults. “The world is not perfect — it never was — but we used to trust our children in it, and they learned to be resourceful,” Ms. Skenazy said. “The message these anxious parents are giving to their children is ‘I love you, but I don’t believe in you. I don’t believe you’re as competent as I am.’ ”

Dr. Gray, author of “Free to Learn: Why Unleashing the Instinct to Play Will Make Our Children Happier, More Self-Reliant, and Better Students for Life,” said in an interview, “If children are not allowed to take routine risks, they’ll be less likely to be able to handle real risks when they do occur.”

Case in point: His college’s counseling office has seen a doubling in the rate of emergency calls in the last five years, “mainly for problems kids used to solve on their own,” like being called a bad name by a roommate or finding a mouse in the room. “Students are prepared academically, but they’re not prepared to deal with day-to-day life, which comes from a lack of opportunity to deal with ordinary problems,” Dr. Gray said. “Over the past 60 years, there’s been a huge change, well documented by social scientists, in the hours a day children play outdoors — less than half as much as parents did at their children’s ages,” he said.

In decades past, children made up their own games and acquired important life skills in the process. “In pickup games,” Dr. Gray said, “children make the rules, negotiate, and figure out what’s fair to keep everyone happy. They develop creativity, empathy and the ability to read the minds of other players, instead of having adults make the rules and solve all the problems.”

Dr. Gray links the astronomical rise in childhood depression and anxiety disorders, which are five to eight times more common than they were in the 1950s, to the decline in free play among young children. “Young people today are less likely to have a sense of control over their own lives and more likely to feel they are the victims of circumstances, which is predictive of anxiety and depression,” he said.

There are also physical consequences to restricting children’s outdoor play because there are no adults available to supervise it. Children today spend many more hours indoors than in years past, which in part accounts for the rise in childhood obesity and Type 2 diabetes. Many elementary schools have even canceled recess, believing it is time better spent cramming children’s heads with facts and figures.

“Childhood should be a time of freedom and play, not building a résumé for college,” Dr. Gray said.

As Ms. Skenazy put it, “if parents truly believe children must be supervised every second of the day, then they can’t walk to school, play in the park, or wake up Saturday morning, get on their bikes and go have an adventure.”

Some 2,000 families were screened by the Discovery Life Channel to find 13 families crippled by anxiety yet willing to have an intervention. “The parents weren’t easy pushovers,” Ms. Skenazy said. “Some were very unhappy to see me at first. But once pride in what their children achieved replaced their fears, they were ecstatic — relaxed and happy instead of crippled with fear.”

Ms. Skenazy spent four days with each family, introducing a different challenge each day. Sam learned to cut cheese and slice a tomato with a sharp knife and then made sandwiches for his parents. He also learned to ride a two-wheeler.

“I don’t guarantee I’ll take away all their worry, just give them the confidence to loosen the reins on their kids,” she said. “Kids need roots and wings. Parents give them roots. I give them wings.”

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