VA Therapists Help Vets Wrestle With Moral Injuries

Some psychologists are gung ho about using prolonged exposure therapy to treat PTSD, but others are more skeptical.

“It’s a terrible therapy, just terrible,” Dr. Bessel van der Kolk, medical director of the Trauma Center at the Justice Resource Center, exclaimed as we walked to a PTSD conference at Penn Law’s Center for Ethics and the Rule of Law. “It merely re-traumatizes vets who have previously been traumatized. You can quote me on that — and you should.”

Other vets and counselors were less outspoken, but equally troubled by this therapy.

“It’s very intense,” observed Cathy Coppolillo, a staff psychologist for nearly a decade at the Clement J. Zablocki VA Medical Center in Milwaukee. “I’d guess that half the people we try to treat with PE get a few sessions into the protocol and disappear. Not only do they go away untreated, but they think all therapy looks like that.

“In those cases, we’ve probably lost the person for good, which feels like the worst way possible to fail a patient,” Coppolillo added. “So if I’m unsure at all about their ability to tolerate PE, we do something else.”

Coppolillo said other VA hospitals around the country have also been reporting a 50 percent dropout rate for PT patients. But Dr. Edna Foa, who invented the therapy, insisted that the attrition rate is no more than 20 percent, which she said was about average for all therapies.

Coppolillo screens her patients for the ones that might benefit from PE because it can reduce the intensity and frequency of nightmares and flashbacks, she said. But not all qualify. Some can’t deal with intense emotions involved in reliving traumas.

“The combat vets I see have learned (via combat experiences and military training before that) that emotions are potentially life threatening, given their ability to destabilize and distract from the tasks at hand,” she told me. “So emotions are more than just unpleasant and unfamiliar – they feel life threatening. And that’s one of the reasons so many vets drop out of treatment.”

Many vets show up at the VA medical center suffering from PTSD as a result of the roadside bombs that blew up their buddies and forced them to begin filling body bags with pieces of their comrades, Coppolillo said. And PE can work for those vets.

But PE is not very effective in treating the wounded soul syndrome, Coppolillo said.

“So many of these vets are suffering with a moral injury because they were forced to do things that violated their moral code,” she explained. “Revisiting these horrible memories can habituate vets to traditional PTSD, but it can’t touch that sense of guilt.

“I think about one vet who had some pretty rough stuff done to him during his year in Iraq, but he’d also done some pretty rough stuff to others,” she said. “”We tried PE, but habituation doesn’t do much for moral wounds. Finally he said to me, ‘I’m just a monster, and I’m going to have to live with that fact for the rest of my life.’”

Without atoning for their actions and forgiving themselves, many vets become stuck – kind of like the “dry drunk” who throws away the bottle, but never finds anything to replace it.

“So many veterans feel they don’t deserve to move forward and live happier, more fulfilling lives, given the ‘monster’ they feel is lurking within them,” said Coppolillo. “This limits the effectiveness of any kind of treatment (including PE) if someone feels they deserve their suffering and that to fix it would be morally wrong. In my experience, this is unbelievably common.”

At the PTSD conference, Foa said she didn’t believe the concept of moral injury was a particularly helpful one.

About a quarter of her patient load at the VA medical center in Milwaukee involves military sexual trauma, Coppolillo said, and they are a little easier to treat than moral injuries.

“My experience has been that PTSD symptoms that arise from sexual trauma seem to resolve a bit more quickly than do symptoms related to moral injury,” said Coppolillo. “My gut sense is that that’s probably because there isn’t the same sense of moral injury holding the symptoms in place.

“Certainly, sexual assault survivors feel a deep sense of guilt/responsibility because of any number of choices they might have made at the time, but that seems to be a really different animal from the deep soul injury many combat vets face,” she added. “‘I made a bad choice and that resulted in my assault’ is very different from ‘The choices I made prove to me I’m a monster.’”

Post-Traumatic Stress Disorder Essential Reads

Trapped in War Zones

We Now Know Where PTSD Lives in the Brain

Another observation is that traumas from the distant past are about as treatable as more recent ones, but they may take longer to treat.

“I think about our Vietnam vets and how lengthy their treatment tends to be,” said Coppolillo. “”They’ve spent years suffering and generally not doing well in jobs and relationships that they end up building their identity around their brokenness. Like moral injury, that identity creates a scaffolding that holds the PTSD symptoms firmly in place, and disassembling that scaffolding tends to be quite a bit of work.

“So is therapy less effective with stuff that’s 40-plus years old?” she asked. “I wouldn’t say that, as much as I would say it’s more effortful and takes longer because there’s more you have to drill through before they’re really ready for help.”

One VA counselor, who’s been working with vets since 1970, said he actually tries to steer vets away from dwelling on past traumas.

“People come to me with their slop buckets and try to dump them on me all the time,” he said. “But I don’t see the need for them to sit and tell me their problems for an hour a day every week for 10 years – that just builds mental memory and reinforces the slop.

“They don’t have to tell me, and I don’t have to listen” said the counselor, who asked that his name not be used because he hadn’t cleared the interview with the VA public information office. “I ask them what their specific problems are and what resources they need to overcome those problems. Then we stack the resources together and allow the vet to process his problems with new resources to collapse the threat.”

Another Vietnam vet told me of his experience with exposure therapy while undergoing PTSD treatment at the Tomah (Wis.) VA Medical Center.

“It was very intense,” he said. “Guys were literally on their knees in tears.” This vet said he told the class how he mistakenly killed two South Vietnamese men that he encountered in the jungle where no one should have been, then checked their bodies and found they were civilians with no weapons.

“It was very relieving (to get that story out),” he said, ‘but I wouldn’t want to do it again.”

One of the major limitations of most therapies, including prolonged exposure therapy, is that they fail to provide vets with a sense of purpose similar to the mission they experienced in the armed services, said Coppolillo.

“If we’re talking about recovery writ broadly for these veterans – not just from PTSD as a narrowly defined diagnosis, but from ways that their military experience has wounded them – this question of meaning and purpose is huge,” she explained. “I spend hours each week discussing it in both group and individual sessions.

“The loss of belonging to something bigger than the self, and of a defined mission, is so painful, and it’s one of the biggest barriers I see for folks trying to recapture/create a life that makes sense,” Coppolillo said.