Stories for ChangeMoral Injury, Soldiers and The Community

Designing For Slow ChangeHuman-Computer Interaction Design: Indiana UniversityDecember 7, 2011

By Candace Buggs, Jeff Wain, Ed Rice and Anna Saraceno

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Moral injury is “perpetrating, failing to prevent, or bearing witness acts that transgress deeply held moral beliefs and expectations may be del-eterious in the long-term, emotionally, psychologically, behaviorally, spiritually, and socially.” (Litz 2009)

Jonathan Shay states that “transparently, we are dealing with an injury, not an illness, malady, disease, sickness, or disorder... It is entirely hon-orable to be injured,” but “to fall ill… is unlucky.” (Shay 2011).

We focused specifically on moral injury, as opposed to Post Traumatic Stress Disorder (PTSD), making the following comparisons between the two:

Injury vs. IllnessMoral injury is just that, an injury, not an illness. Moral injury is sustained by soldiers in wartime just like a physical injury. The mental effects of both these injuries are also damaging and can lead to issues such as PTSD, yet are fundamentally different problems. PTSD is a disorder, categorized as an illness, carrying its own undesirable stigma.

Honorable vs. UnluckyThe problem with moral injury is that it isn’t considered honorable. Both the community and the military consider mental and moral injuries as unlucky, while a physical injury has traditionally been perceived with respect as honorable wounds, commemorated with ceremonies, monu-ments, the purple heart, and other decorations.

Respect vs. DoubtAs veterans return from war with physical injuries, the communities around them often treat them with respect, seeing their injuries as hon-orable. However, a disparity exists when soldiers suffer moral injury. When community members hear soldiers’ stories of wartime experi-ences, they often develop feelings of doubt towards the soldiers. The community may expect soldiers to be emotionally unstable, then no

longer trust the soldiers. The community may doubt that a soldier can be truly “disabled” due to the invisible nature of moral injury. Finally, the community may doubt that something so terrible could have realistically happened, even in a war zone. This doubt weighs on a soldier heavily, exacerbating the problems associated with moral injury.

Design coreHelp soldiers cope with moral injury by acknowledging the cause of the injury, teaching the community about the soldiers’ experiences at war, and making progress towards decreasing soldiers’ suicide rate and in-creasing the strength of community support networks.

Target domainVeterans returning from the war in Iraq and Afghanistan who are begin-ning or continuing a college career. This environment hosts unique chal-lenges to overcome for the soldiers and the communities they return to.

Target contextCoping with moral injury from issues of guilt resulting from experiences during deployment. Specifically, how soldiers deal with and are affected by permissible collateral damage in their role as a soldier, and how it conflicts with their moral identity after returning home.

Target usersVeterans who served in Afghanistan/Iraq returning from their last tour of duty without reinstatement. We’re looking at veterans as they return to civilian life and reestablish their moral compass.

What is “moral injury?”

Project summaryFor most U.S. soldiers returning from Afghanistan and Iraq, the transi-tion from life as a soldier to a civilian role is a jarring one. During this transition, there are significant differences in lifestyle, structure, and un-derstanding of “normalcy”. Coupled with struggles overcoming moral injuries sustained on the battlefield, for many soldiers this transition can be difficult at best, especially as they redefine their understanding of normal and purpose in their everyday life.

Though many of these soldiers seek and are provided counseling, the burden of self-motivation can often be too much to overcome. Counsel-ors and instructors often cannot connect closely enough with the trau-matic experiences these soldiers have experienced. When sharing their stories of war, the people they try to share their stories with are often unprepared to hear and accept those stories. Other returning soldiers and veterans end up being the only resource soldiers can turn to com-fortably to share their thoughts and frustrations, as their experiences as soldiers have so strongly shaped their understanding of the world.

We are creating a tool that will help soldiers ease the transition back to their communities by building support and understanding of moral injuries faced by today’s soldiers. By addressing the misunderstandings surrounding moral injury by the non-military public in the U.S., we hope to reshape understanding of moral injury so new support networks can be built to affect long-term support of veterans.

Research findingsToday, more soldiers die from suicide than from physical injuries in com-bat. Since 2008, there have been more suicides than combat deaths in the U.S. military. In 2010, there were 468 military suicides while 426 soldiers were killed in direct combat. The 2008 U.S. suicide rate was 11.7% per 100,000 citizens, in the U.S. Contrasted with the military sui-cide rate at 16.3% per 100,000 citizens, and an obvious disparity exists. This is in some part due to wartime experiences, but is also due to the changing nature of war (Ramchand 2011, Jefferson 2011).

In the past, many more soldiers have died from complications of their wounds than immediately on the battlefield. When a shell fragment takes off a soldiers arm, severing arteries and nerves, the primary wound isn’t the killer, but rather the later complications and contamina-tion of that wound. Advances in modern medicine and treatments have made physical wounds significantly more survivable. As the ability to treat physical wounds progresses, so does transparency of the effects of psychological damage to our soldiers. Johnathan Shay suggests that psychological wounds have their own complications. Specifically with moral injuries, the primary injury of a traumatic experience, if not treat-ed, can become complicated and contaminated in the weeks, months, and years to come. And, in some cases, they can be just as fatal as a physical injury. Not only have researchers found a link between moral injury and suicide, but they have identified a higher suicide rate among soldiers not diagnosed with PTSD (Zivin 2007). If Joseph Minard’s fa-mous visualization of Napoleon’s March (Tufte 2002) were contrasted to today’s wars, the casualty rate might show many more soldiers return-ing home only to die by their own hands.

Traditionally, wars have been symmetrical in nature. When a war began, military personnel and soldiers knew their roles, where they would be, what combat situations they would be subjected to, and their involve-ment in the war itself. Today’s wars, however, have become increas-ingly asymmetrical. Nearly all military roles, save stateside leadership, are in some way exposed to combat or the effects of war. But even U.S.-based roles are not shielded from the effects of war as remote operations increase, as is the case with drone operators. This changing nature of a military role causes an increase in exposure to events that cause moral injury. Programs such as the Army’s “Resiliency Training” (formerly Battlemind Training) try to prepare all Army roles for instances of combat, but still leave out proper acknowledgement of and prepara-tion for moral injury and mental stress.

The moral injuries sustained by deployed soldiers often come from three different kinds of guilt identified by Sherman:

• Guilt from accidents (e.g., misfiring a weapon and killing a fellow U.S. soldier)

• Guilt from collateral damage (e.g., killing a child because of the pos-sibility that he or she may be holding a bomb)

• Guilt from “luck.” (e.g., a surviving soldier finds it “lucky” that he survived and another fellow soldier did not) (Sherman 2010, 2011)

To expand upon the concept of guilt from luck, Sherman explains many soldiers’ feelings that “to have good luck is to deprive another of it” (Sherman 2011). Ultimately, many soldiers reason that to survive war means that someone else died in your place.

Litz identifies eight steps for overcoming moral injury (2009). These prin-ciples heavily influenced our design and are based on the seminal and most comprehensive study of moral injury. We drew the most influence and inspiration from the third principle, “Modified Exposure,” which outlines re-framing the ways in which moral injury should be defined, shared, and exposed by soldiers.

1. Connection Need for exposure on the side of caretakers and counselors for genuinely respectful support

2. Preparation and education A plan of action and sharing of shameful material without condem-nation is crucial to create a healthy life.

3. Modified Exposure Reliving experiences and becoming exposed to transgressions are necessary for change

4. Examination & Acceptance Separation of event and self, appreciation of context and imperfect self

5. Conversations with benevolent moral authority Connecting with someone respected and in a higher moral position

6. Reparation & Forgiveness Make amends and move toward positive, better living

7. Fostering Reconnections Redefining identity, social connections, and reconstructing caring and loving relationships

8. Prepare for the Long Haul Redefinition of self and goals

Some resources exist to connect war veterans with each other for the purpose of support and healing. For example, the Iraq and Afghanistan Veterans of America (IAVA) seeks to “improve the lives of Iraq and Af-ghanistan veterans and their families” and “build an empowered gen-eration of veterans who provide sustainable leadership for our country and their communities” (IAVA.org 2011). While the IAVA’s website and other similar resources may be effective in connecting veterans with each other, they don’t necessarily address the importance of the com-munities to which the soldiers return after war. This gap in resources presented a strong problem space for finding ways to help soldiers cope with moral injury.

We found through both primary and secondary research that utilizing storytelling would be a powerful way to evoke the emotional response necessary to exact change in this difficult problem space. Not only is storytelling an effective therapy tool in other fields, like cancer treat-ment, child therapy, religious coping methods, and rehabilitation, but has already been proven to be an effective treatment method for PTSD. Finally, storytelling is already the primary coping method for moral injury used by soldiers. (Weg 2011, Crawford 2004, Trappler 2007, Brinkman 2011).

A framework for slow change Our design seeks to provide change of perspective for both the soldiers as well as the community. In the book Switch by Heath and Heath, the authors discuss three key elements to achieving change: open-mind-edness, hope, and imagination (which we modified to creativity). Heath and Heath also identify the slow-change concepts regarding “scripting the critical moves” and “growing your people”. Our final concept was based on a combination of Heath and Heath’s slow change concepts and Litz’s eight-step process to overcoming moral injury.

Slow change in soldiersWe identified the soldiers’ critical moves as writing and sharing their experiences during deployment. Because acknowledging and sharing their experiences is part of Litz’s eight-step process, this action also

speaks to the notion of “growing your people”. Through the storytelling process, which allows the soldiers to cognitively offload some of their most troubling memories, the soldiers will be able to come to terms with what happened during their time at war, and begin to heal from moral injury.

Slow change in the communityFor the communities to which soldiers are returning, the critical moves include viewing the website, visiting the public installations, and reading and listening to soldiers’ stories. The resulting awareness and shared understanding within the community is crucial to the community’s slow change. We are growing the community by preparing them to under-stand the soldiers’ experiences and provide better support networks for returning veterans.

Measuring changeIdeally, the implementation of our design will have the following positive effects on soldiers and their communities:

• Increased awareness within the community of the soldiers’ deploy-ment experiences

• Increased awareness and acknowledgment of moral injury by the military and public

• Decreased long-term psychological issues in soldiers• Lowering the barrier that prevents soldiers from getting help• Increased ability of the general public to help soldiers cope with

moral injury• Improved support networks within the military and public for moral

and mental injury

To measure success, we plan to use the following metrics:

• Decreased suicide rate among war veterans• Consistent increase in the number of stories shared in our system• Consistent increase in the number of stories read or listened to• Increase in the number of public installation locations and visibility

Concept mapThis design is supported by a process concept map illustrating the changes we hope to affect in the soldier and community. The map con-sists of three parts supplemented by Litz’s seminal paper outlining a model of eight steps of treating moral injury (Litz 2009). The outer circle of the model represents the process of changing perception and un-derstanding of moral injury. The inner circle represents the process of treating moral injury by the soldier and in community support networks. The three sides of the triangle of change in the center of the model map to both the inner and outer circles, with two aspects (the two end points) of each side as the key points of change.

How it worksAt the end of a soldier’s tour, they are able to share their stories of moral injury they suffered while deployed. This is promoted primarily during the two- to three-week decompression period after deployment while the stories are the most poignant and fresh in the mind of the soldier. Writing out their stories at this point serves as a coping mechanism and allows them to release some of the burden of the story while in the company of other soldiers before having to return home. An inter-view with one Army veteran of Iraq revealed that there is little support for mental and moral injury during this decompression period. Sharing these stories will help soldiers to feel as if the military does care for their well-being even after transitioning out of service.

One aspect of the design is a publicly-available website featuring sto-ries shared by soldiers. Upon visiting the site, a story is prominently fea-tured as the main content of the page. Stories are textual but may also be accompanied by a recorded audio version. Shared stories consist of a title, the location of the story, the date shared, the textual story, and the optional accompanying audio. Visitors to the site navigate between stories, scrolling horizontally between stories in an infinite loop to the left (older stories) or right (newer stories). For the public, the intent is to allow them to connect with soldiers, gain insights into these intense experiences, and learn about the realities of wartime and the real (and often invisible to the public eye) effects on those soldiers.

A map view accompanies the stories. By clicking on the location the story is shared from, visitors will be brought to the map which displays the support for each story. This support is shown through circles that appear on the map over areas from which people have offered support. This support includes people who have read the story online, people who have read the story in public installations (based on number of touches and/or visitor counts), and people who have shared the story. Organizations in the community can also show support and market their services through the use of the map. Veterans using the system are weighted more heavily than the general public and future iterations of this design may offer the possibility of internal feedback to each story.

Stories are also shared on public installations. These displays feature large numbers of stories slowly scrolling upward on large screens. The sheer number of stories should be enough to communicate the gravity and prevalence of moral injury in veterans. The text should be readable from 5-6 feet away, but small enough that many stories can be dis-played at once. The scrolling needs to be slow enough so that the aver-age person can read a story as it scrolls, but fast enough to give a sense that the stories will continue to appear. The nature of the display allows for a variety of sizes, and whether a large projection, an array of TVs, or even a large flatscreen, should still evoke the same emotional response.

Soldiers write or record stories on the site. Soldiers are prompted to describe their ordeals and troubles during and resulting from war. For soldiers, this website offers them a way to teach the community about their experiences and the non-physical effects of war. Our goal is to em-power them to share these intensely personal and painful experiences and educate the public on the realities of wartime experiences. Sharing these experiences through writing is significantly easier for soldiers than sharing them in person, a lengthy, difficult process for the soldier which many civilians reject, don’t know how to respond to, or can’t deal with.

Identifiable information is never shared. Stories must be moderated be-fore being shared with the public so as not to violate OpSec (Rules of Operational Security) laws.

This design needs to additionally consider integration with existing net-works so as to validate soldiers. While we do not want to limit this to

soldiers willing to put out the effort to register for a service such as the IAVA--a difficult process requiring two forms of military ID--the benefits of leveraging existing support networks and privacy to veterans would be a good entry point. Internally, we would also hope that in the future veterans will be able to respond to and offer support to the soldiers sharing their stories. Soldiers, and eventually the public, should in the future be able to aggregate and follow stories of interest to them.

Design requirements• Provide the ability for soldiers to share their stories• Create a community-facing display or installation of stories• Provide a constant feed of stories on a publicly-available website• Ability to share, spread, and collect stories outside of the feed

(Facebook, Twitter, collection, etc.)• Allow soldiers to view only his/her posts• Abide by the Rules of Operational Security (OpSec)• Provide a map of support--showing supporters (both individuals

and organizations), soldiers, readers, etc.• Answer to identification issues (internal, external, etc.) and ano-

nymity

PersonasThe three personas we have created are based on research investigat-ing soldiers in Iraq and Afghanistan. We chose these particular three to represent the current most affected population of soldiers returning from the war. Each has experienced moral injury and represent an ar-chetype that would realistically be returning to pursue a college degree after military service.

Today’s deployments are more frequent and longer (15-18 months) than in any war in the past due to the number of soldiers in the military overall and the length of the engagement. Looking at Virginia Shaw, though uncommon, it is not unprecedented for a female soldier to have taken a front-line role similar to hers in Iraq. Her squad served a sup-port role, not recon or front-line combat, and her persona resonated

particularly strongly with one soldier we interviewed. Luis represents many of today’s soldiers and contractors serving military policing roles. Alex Black’s situation is, unfortunately, one of the most common types of situations and profile of soldier most likely to be strongly affected by moral injury.

StrategyIn order to gain critical support for our design, one of the first hurdles to address is integration into the military decompression process. Expos-ing soldiers to this design during that process and offering support to this overlooked area of difficulty is critical. Not only for our design, but also for treatment and acknowledgment of this issue by soldiers. An ad-ditional need is to identify potential access points or support systems this design could leverage. The IAVA already offers a support network to veterans of Iraq and Afghanistan and may be a good fit to offer vet-eran support behind the scenes for these stories.

Awareness for the system will need to be grown through a public aware-ness campaign and deployment of numerous public installations. An identified strength of this system is to aggregate stories as they ac-cumulate for later research by organizations such as the APA and VA for empirical studies and to drive future research. One large area we would also like to address is how to support military contractors. These contractors are a large part of the deployed military combat force in Iraq and Afghanistan. They too are experiencing and coping with moral injury in similar ways as the military, however they are without any form of military support or acknowledgment as a veteran.

ConclusionWe sincerely believe our design can affect large-scale positive changes in veterans of Iraq and Afghanistan and the community. The long-term effects of reshaping public understanding of moral injury, we hope, will be able to create lasting and significant changes in support of veterans and their ability to cope with and overcome the effects of moral injury.

ReferencesAquino, K. et al. (2007). A grotesque and dark beauty: How moral identity and mechanisms of moral disengagement inXuence cognitive and emotional reactions to war. Journal of Experimental Social Psychology. 43, 385–392.

Brinkman, W.-P. et al (2011). Cognitive engineering of a military multi-modal memory restructuring system. Journal of CyberTherapy and Rehabilitation, 4(1), 83- 99.

Craine, W.C. (1985). Theories of Development. Kohlberg’s Stages of Moral Development. Prentice Hall. Chapter 7, 118-136.

Crawford, R. et al (2004). Storytelling in Therapy. Nelson Thornes Ltd. Cheltenham, UK.

Fineman, H. Paul Rieckhoff: Iraq And Afghanistan Veterans Of America Founder (The Inspiration-als). The Huffington Post. 11/26/2011. Retrieved from http://www.huffingtonpost.com/2011/11/26/paul-rieckhoff-iraq-afghanistan-iava_n_1113541.html on 11/28/2011.

Haidt, J. (2001) The emotional dog and its rational tail: a social intuitionist approach to moral judg-ment. Psychological Review. 108, 814-834.

Jefferson, C. (2011). More U.S. Soldiers Killed Themselves Than Died In Combat 2010. Good.is. 01/27/2011. Retrieved from http://www.good.is/post/more-us-soldiers-killed-themselves-than-died-in-combat-in-2010/ on 11/28/2011.

Litz, B. et al. (2009). Moral injury and moral repair in war veterans: A preliminary model and inter-vention strategy. Clinical Psychology Review. 29(8), 695-706. ISSN 0272-7358.

Mejia, Camilo. PTSD Symposium 2011- Moral Injury- Mejia -Veterans for Peace. PTSD Sympo-sium 2011. Presentation, 04/23/2011. Portland, MN, USA. Retreived from http://www.youtube.com/watch?v=wqyf2dmbeOg on 11/15/2011.

Ramchand, R. et al. (2011). The War Within. Prepared for the Center for Military Health Policy Re-search. RAND Corporation. Santa Monica, CA, USA. ISBN: 978-0-8330-4971-1

Shay, J. (2011). Casualties. Daedalus Quarterly. 140(3), 179-188. doi:10.1162/DAED_a_00107.

Sherman, N. Soldiers’ Moral Wounds. April 11, 2010. The Chronicle of Higher Education. Retrieved from http://chronicle.com/article/Soldiers-Moral-Wounds/64987/ on 12/03/2011.

Sherman, Nancy. (2011) The Guilt They Carry: Wounds of Iraq and Afghanistan. Dissent. 57(2), 80-84). DOI: 10.1353/dss.0.0137, (2011).

Sherman, N. The Untold War: Inside the Hearts, Minds, and Souls of our Soldiers.

Silver, D. Beyond PTSD: Soldiers Have Injured Souls. 09/01/2011. Miller-McCune. Retrieved from http://www.miller-mccune.com/culture/beyond-ptsd-soldiers-have-injured-souls-34293/ on 11/15/2011.

Starkman, R. Veterans of Iraq and Afghanistan Need Support in College! The Huffington Post. 05/29/2011. Retrieved from http://www.huffingtonpost.com/ruth-starkman/veterans-of-iraq-and-afgh_b_868602.html on 11/28/2011.

Trappler, B. and Newville, H. (2007). Trauma Healing Via Behavior Therapy in Chronically Hospital-ized Patients. Psychiatric Quarterly. 78(4), 317-325. DOI: 10.1007/s11126-007-9049-8.

Tufte, V. and Finley, D. (2002). Minard’s Sources. EdwardTufte.com. Retrieved from http://www.edwardtufte.com/tufte/minard on 11/28/2011.

Weg, A.H. (2011). OCD Treatment Through Storytelling: A Strategy for Successful Therapy. Oxford University Press. New York, NY, USA.

Zivin, K. (2007) Statement before the House Veterans Affairs Committee. VA.gov. Retrieved from http://www.va.gov/OCA/testimony/hvac/071212KZ.asp on 12/7/2011.

Personas

Page 1Edward Simpson. “Frederica and some guy.” Re-trieved from http://www.flickr.com/photos/king-ed-

ward/4216117263/ on 11.28.2011.

Page 2Flickr user doug88888. “Man head.” Retrieved from http://www.flickr.com/photos/doug88888/2971792454/sizes/o/in/photostream/ on 11.28.2011.

Page 3Flickr user 1 Photo. “PICT0204.” Retrieved from http://www.flickr.com/photos/1photo-oc6/3187390332/sizes/l/in/pool-flickr_mil/ on 11.28.2011.

References

Experiencing military and civilian IED effects firsthandMemories of wartimeSexual harrassment early in her serviceLoss of squad membersThree deployments to Iraq Nerve damage to her right arm and legMigraines from two IED blasts

Moral

Mental

Injuries sustained

Sources of difficultyDoesn’t feel as close of a connection to her husband after returning home, feels as if it is failingTrouble adjusting to student life

Injury

Sophomore, University of MichiganB.S. Communication Sciences, Business AdministrationMarines, 8 years of service. Three tours in iraq.29 years old. Married. No children.

Sgt. Virginia Shaw returned from her last tour of duty in Iraq in September, 2009. Three deployments were not easy on her. Though successful in her role, her service left little time for her to return home to her husband and start a family or pursue personal goals like returning to college for an MBA. Virginia’s transition back to civilian life was not an easy one at first, especially with the loss of structure and rank. The daily support and companionship of her squad was instrumental in her success, and with that essential piece of her routine missing, she feels as if an integral part of her life is missing.

Virginia rose through the ranks in the service quickly, ending up as Sergeant after only seven years of service, receiving her promotion during her third—and final—tour of duty. During her final deployment, her squad succeeded in taking a number of major tactical positions, but she lost three soldiers, a major blow to her confidence as an of-ficer. She survived two IED blasts, one of which has given her recurring migraines, and the latter which put her up in a medical facility for three weeks with damage to her right arm and leg.Recurring dreams of her time deployed are a constant struggle.

Though driven, Virginia has a large amount of stress resulting from her experiences as a soldier. The difficulty adjusting back to a student life after eight years in the military was exceedingly difficult for her. She would have dropped out of school after her first year back, were her recruiter and in-laws not so supportive of her. She’s had a very difficult time explaining her experiences to those around her. They don’t understand what she’s gone through.

Marine Sergeant Virginia Shaw

GoalsStart a family now that she’s back home with her husbandPursue an MBA and hopefully start her own business

MotivationsStarting and supporting a familyHigh sense of self-worth and motivation to succeed

Support networkHusband Squad In-laws Physical therapist Veterans’ Association (VA)

Moral

Mental

Physical

Social

Familial

Experiential

Physical

Environmental

StressorsLow High Low High

Physical

Weak Good Strong Weak Good

Seeing the effects of war on families in KandaharTwo dangerous deployments to KandaharMemories of wartimePhysically strenuous deployments

Moral

Mental

Injuries sustained

Sources of difficultyAgoraphobia, onset from his time in AfghanistanDiminished trust of strangersSignificant trouble handling class sizes and crowds at GSUDifficulty overcoming his memories of war

Physical

Spc. Nuñez spent the first of his deployments to Afghanistan in a machine gun squad patrolling the borders of Kandahar. His last tour was spent policing the city of Kanda-har. Luis found the stresses of war exacerbated during his time deployed there. Not only was Luis in charge of keeping his squad safe, but he also was in charge of keeping families, kids, and regular citizens of the city safe. Luis often feels appreciation of his role than his fellow soldiers since he was stationed in a city, despite it being the most dangerous part of the country. The burden of seeing the after-effects of the loss of fam-ily members was not an easy to witness, especially having a family of his own at home.

One of Luis’s most difficult experiences witnessing a car bomb explosion that killed some of his fellow soldiers. Luis had a hard time justifying their loss, thinking that he should have been there instead. After the blast, his squad helped secure and clean the area, an experience that still hasn’t left his mind even five years later.

His training led him to want to pursue a degree in physics after returning to school. The stress of working in the city with those people who were—at first—afraid every day made him want to leave that behind. Luis hopes that a focus on the sciences after his technical training in the Army will allow him to focus on something that won’t cause him to regress into some of memories he struggles with on a daily basis. Fortunately, Luis recognizes the difficulties he faces and has looked for outside support to get him through his time at Georgia State University. His wife and kids are a constant source of encouragement. His support network is fairly strong and Luis has no qualms with shar-ing his experiences with his therapist.

Army Specialist Luis Nuñez

GoalsFinish a degree in physics and leave the military to support his familyBuy a house off the military base

MotivationSupport his family and invest time with his children now that he’s backAcknowledgment of daily difficulties he faces

Support networkFamily Veterans at GSU Therapist IAVA School mentor

Junior, Georgia State University, B.S. PhysicsArmy, 7 years of service, active duty. Two tours in Afghanistan.26 years old. Married. Two children.

InjuryMoral

Mental

Physical

Social

Familial

Experiential

Physical

Environmental

StressorsLow High Low High

Strong Weak Strong Good Weak

Freshman University of Texas at San Antonio, B.A. Political ScienceArmy, 4 years of service, Active duty.One tour in Afghanistan, one tour in Iraq. Divorced.

After his second tour deployed in Iraq, the stress of war was too much for Alex to handle. His first deployment was stressful enough after losing his best friend, then after his wife left him he was ready to head back out for a second tour. He requested rede-ployment and left for Iraq two months after returning home.

On the battlefield, Pfc. Black follows orders to the “T.” Though always willing to take on more, Alex doesn’t invest the time to make sure the outcomes are above and beyond what has been requested. To his fellow soldiers, it seems as if he isn’t invested, but on the contrary, he usually over-invested himself in each and every mission to the point of having difficulty separating them from his daily thoughts and spilling into his free time. Before being discharged, one of his commanding officers made some very question-able calls. On one occasion, Black’s squad ended up killing what turned out to be a family taking a taxi.

After his divorce, Alex distanced himself from the responsibilities, instead focusing on supporting his squad. Alex’s need to distance himself from the battlefield began when his closest friend, Pfc. Rod Chambers, and commanding officer were killed in a firefight.

Still very prideful, Alex does not want to see any sort of therapist after returning home, wanting to keep up a personal facade of mental and physical strength. His experiences put more stress on him than he realized he could handle, and have pushed him to what would likely be diagnosed as PTSD if he would seek counseling. He’s tried to share his stories with his old friends, who wouldn’t even sit through them, making Alex feel even more an outcast.

Army Private First Class Alex Black

GoalsGetting out of the military to help shape public policy based on his experiences

MotivationGetting out of the line of fire permanentlyChanging policy to help soldiers currently deployed through politics

Support networkSome old friends School advisor Email contact with squad

Questionable orders from CO resulting in civilian casualtiesMessy divorce between his two deploymentsLoss of his best friend, Pfc. Rod ChambersPTSDTwo back-to-back deployments

InjuryMoral

Mental

Physical

Social

Familial

Experiential

Physical

Environmental

StressorsLow High Low High

Moral

Mental

Injuries sustained

Sources of difficultyStrong desire not to be redeployed as he finishes out his service in the ArmyNo support network and no desire to build oneRefusal to acknowledge problems he encountersDistrust of judgments from those in leadership positions

Weak Weak Weak

Process concept map

Moralinjury

Community

Soldier Perspective

Stories

Prepare

, cope

Understand

Treat, support, respect

Writ

e, re

leas

e

Read, share, disseminate

Changing personal identity

Collective understanding

Growing identityGoal direction and action triggers

Defi

ning

iden

tity

Sha

re th

e st

ory

Decompression, mental fortitude

Imagination Hope

Open minds

Con

nect

ion

Iden

tify

the

wou

nd

Dress the wound

Perception

Modification

Acknowledge the wound

ConnectionNeed for exposure on the side of caretakers and counselors for genuinely respectful support

Preparation & EducationA plan of action and sharing of shameful material without condemnation is crucial to create a healthy life

Modified ExposureReliving experiences and becoming exposed to transgressions are necessary for change

Examination & AcceptanceSeparation of event and self, appreciation of context and imperfect self

Conversations with benevolent moral authorityConnecting with someone respected and in a higher moral position

Reparation & ForgivenessMake amends and move toward positive, better living

Fostering ReconnectionsRedefining identity, social connections, and reconstructing caring and loving relationships

Prepare for the Long HaulRedefinition of self and goals

Brett T. Litz, Nathan Stein, Eileen Delaney, Leslie Lebowitz, William P. Nash, Caroline Silva, Shira Maguen, Moral injury and moral repair in war veterans: A preliminary model and intervention strategy, Clinical Psychology Review, Volume 29, Issue 8, December 2009, Pages 695-706, ISSN 0272-7358,

Progress

Moralinjury

Understanding

Community

Soldier Perspective

Stories

Prep

are, c

ope

Understand

Treat, support, respect

Writ

e, re

leas

e

Read, share, disseminate

Decompression, mental fortitude

Imagination Hope

Open minds

Con

nect

ion

Iden

tify

the

wou

nd

Dress the wound

Perception

Modification

Acknowledge the woundSoldier &

Community

Moralinjury

Understanding

Community

Soldier Perspective

StoriesPr

epare

, cope

Understand

Treat, support, respect

Writ

e, re

leas

e

Read, share, disseminate

Decompression, mental fortitude

Defining identityShare the story

Imagination Hope

Open minds

Con

nect

ion

Iden

tify

the

wou

nd

Dress the wound

Perception

Modification

Acknowledge the wound

Moralinjury

Understanding

Community

Soldier Perspective

Stories

Prep

are, c

ope

Understand

Treat, support, respect

Writ

e, re

leas

e

Read, share, disseminate

Changing personal identityCollective understanding

Imagination Hope

Open minds

Con

nect

ion

Iden

tify

the

wou

nd

Dress the wound

Perception

Modification

Acknowledge the wound

Understanding

Community

Soldier

Stories

Prep

are, c

ope

Understand

Treat, support, respect

Writ

e, re

leas

e

Read, share, disseminate

Imagination Hope

Open minds

Con

nect

ion

Iden

tify

the

wou

nd

Dress the wound

Perception

Modification

Acknowledge the wound

Perspective

Decompression, mental fortitude

Growing identityGoal direction and action triggers

Moralinjury