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How this psychologist treats soldiers who can’t let go of what they did at war

Dr. Patricia Resick is a professor of psychology at Duke University and a therapist who was formerly the director of the women’s health sciences division of the National Center for PTSD. She is also the creator of cognitive processing therapy (CPT), a treatment for trauma that she has used to help veterans suffering from trauma, including those who are struggling to come to terms with their actions in battle that they now believe were wrong, even unforgivable.

Experts generally refer to that struggle as "moral injury": the psychological pain that results from a transgression of deeply held moral beliefs. Sometimes that transgression is something the service member did, such as killing a civilian. Other times it is an omission — for instance, a failure to prevent the death of a fellow soldier in battle. Moral injury can also result from a betrayal by a commanding officer or other superior.

Dr. Resick spoke to me about how CPT is used to help veterans heal from moral injury (although she prefers not to use that term, which she finds limiting and somewhat judgmental). Her message was that it is possible to heal from moral injury, but that doing so requires a shift in the way patients think about war, morality, and themselves. This interview has been condensed and edited for clarity.

Amanda Taub: You see a lot of patients who are traumatized by the moral consequences of what they did in war. Do you think people who fight in today's wars are particularly prone to that?

Patricia Resick: They grow up on video games and they romanticize war. And then they go to an actual war zone, and it’s not like being in a video game. There’s real death, and there’s real blood and real guts, and they may come home and think, "Oh my god, I killed somebody. That’s against my values."

I’ve actually heard people say this: "I thought I was going to go to the war zone and not be shot at, not have to shoot anybody."

I mean, they’re 19-year-olds.

Amanda Taub: Do you think they blame themselves for the fact that war didn't work out the way they expected it to?

Patricia Resick: When traumas happen to us, we like to think we had a role in it, or we caused it, because that gives us a sense of power that we can stop bad things in the future. "If I don’t do this, another bad thing won’t happen to me."

If you let go of that self-blame, then you’re stuck with the idea that somebody else had control in that situation, or some other forces had control in that situation. That’s a really scary idea — to think that traumas can happen to you again.

We talk a lot in cognitive processing therapy about the "just-world" myth. The just-world myth is that good things happen to good people, and bad things happen to bad people. So if something bad happens to you, you assume you must have done something wrong. And we’re all taught it. Most adults think they don’t have it, but as soon as they ever say, "Why me?" they’ve admitted to the just-world belief.

Amanda Taub: Does that kind of just-world thinking apply on the battlefield, as well?

Patricia Resick: I hear a lot of soldiers say, "That guy over there in the next truck, he was such a nice guy. It’s not fair that he was killed! He’s got a wife and kids."

And then [in therapy] we’ll ask the question: "Well, do you think the person who shot off that rocket picked him out because he has a wife and kids? Or didn’t pick you because of a particular reason?"

"No."

"So that’s not really relevant that he has a wife and kids — the rocket just happened to hit him?"

"But that’s not fair!"

"Yeah, that’s right. War isn’t fair. Nor is life."

Amanda Taub: Does that work the other way, as well? Do you find that veterans worry they killed someone who could have been a good person, and that makes their actions so much worse?

Patricia Resick:A therapist would say, "But what did you know, what did you think at the time? And if you hadn’t shot him, and he did have a gun, and you thought to yourself, 'What if he’s a pediatrician?' and you paused and then he shot your friend, then what would you think?"

We try to flip it on its head and have them think about alternative outcomes, and that they did the best they could under the circumstances, with the knowledge they had.

They’re not God. And yet they have this concept, "I’m responsible for my men."

Even if somebody has some responsibility — say, he didn’t wait long enough to find out if the person had a gun, and his commander says, "You made a mistake," — sometimes I will say, "Did you get court-martialed?" And they’ll say, "No."

And I’ll say, "Oh, so did they decide it was your fault, when they did the debriefing afterward?"

"No."

"So why are you deciding that?"

You have to help them look at other alternatives, because they’re only playing it out one way. They’re not thinking about what could have happened if they did something differently.

Amanda Taub: What if the unit commander or debrief did find that the soldier had done something wrong?

Patricia Resick: Our goal is to right-size it, because they’ll take it and run with it.

This veteran might be thinking about all the horrible things that have happened because he killed this guy: "Maybe he’s the pediatrician. Maybe he’s the father and sole support of five children. What does that make me? That makes me a monster."

Now I want to right-size that. "Is that all you are, a killer? If we were going to fill up a pie chart with all of the things you are, what percentage are you a killer? What else are you? Okay, you’re a husband. You’re a worker. You’re the son who goes over and cleans out his mother’s gutters once a year, and takes her out to lunch on Sundays. You are the deacon in your church."

You have to start making it more proportional. Saying, "Yes, you have killed. And you have regrets that you have killed. But where does all the rest of this stuff fit in with that concept, 'I am a monster'? Or, 'I should not be around other human beings'?"

Amanda Taub: It seems like what you’re describing is a system of moral proportionality that’s pretty absent from the way we often make judgments about people's character. We often view someone as "a criminal," for instance, rather than "somebody who had committed a particular crime." Does that tendency make it hard for moral injury patients to deal with these kinds of questions?

Patricia Resick: You’re absolutely right, society reinforces that whole idea. Society plays a huge role in how we then treat people after they have had a single event happen, or even a series of events.

"I thought I was going to go to the war zone and not be shot at, not have to shoot anybody"

There are a lot of people who made a mistake, or did something on impulse, and they now have a reaction to it. They have PTSD because of this action or event that they committed, even if they only intended it for a second. [Maybe] they lost their temper and assaulted someone. Well, yeah, you’re not supposed to assault people. But you’re more than just a criminal.

They’re still the same person. They just have committed a crime.

Amanda Taub: What about people who are traumatized by an omission rather than an act? For instance, by a sense that they should have saved someone? Do they also have trouble putting their decisions in the broader context?

Patricia Resick: Something I see a lot of is this whole concept of being "responsible for your men." They don’t differentiate responsibility from control.

You can train and train and train, but that doesn’t mean that in the situation everybody’s going to do what they’re supposed to do. But then you say, "It’s my responsibility; I should have trained them more." Or, "I should have been there; I should have controlled the situation."

You see these people taking on responsibility for things they didn’t even do, or acting as if they could have control in a situation that is not in their control.

They’re not God. They don’t have total control over a battle. And yet they have this concept, "I’m responsible for my men." They really take it literally. And then whatever happens to them is their responsibility. And then they extrapolate that to "and therefore it’s my fault."

When we’re doing the therapy, we have to parse all of that out. We have to look and see if they had any control in that situation.

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