Pernicano Play Creations

USING STORIES AND METAPHORS

Four reasons to use stories, metaphors and playful interventions in psychotherapy

Dr. Pat's Reflections

12/15/22 

Acceptance and Forgiveness Therapy (AFT) for veterans with moral injury (Pernicano & Haynes, 2018)

Veterans with moral injury carry burdens of guilt, grief, shame, and/or betrayal that keep them stuck and prevent healing. They ruminate about the past and carry unspoken memories of experiences that when they were lived were not addressed or resolved. What they carry is not easily resolved through traditional trauma-informed therapies. They were betrayed by others or engaged in guilt-worthy actions with or without orders, and they became interpersonally disconnected, doubting their worth and often struggling with the desire to end their lives or to reek revenge. Most entered the military at young ages when persons are not prepared for what they might encounter during training, combat or military service. 

Moral injury arises from sanctioned and unsanctioned activities that violate core values. AFT addresses moral injury through story & metaphor with non-judgmental group forgiveness that results in acceptance of self and others. A powerful veteran-to-veteran reconnection develops during the group, and trust is born through sharing long-hidden stories. 

Many consider their actions to have been unforgivable and live with unresolved, punitive guilt. AFT incorporates concepts of confession, including spiritual and legal, and forgiveness by a benevolent other. One “other” is a fair, compassionate judge who releases a person with time served. This concept resonates with veterans who carry shame and guilt. They acknowledge that they have carried a burden a long time and perhaps they can choose to let it go, with the group’s help. They are not alone in their pain, and the group response to their stories stirs compassion for themselves. 

Whatever you are carrying, consider “time served,” and allow your life to reflect your worth rather than focusing unduly on your failures. The past does not have to define who you are now, although it is woven into your tapestry of life experiences. 

11/28/19 

Moral Injury in Veterans

After working with trauma and attachment issues for many years at non-profit settings  (family reunification, child abuse/neglect, out-of-home youth), I decided to take my work to the Veteran's Administration. I had been reading about Moral Injury for a year or two and soon after being hired, sought to work with a VA Chaplain to lead a group for Veteran's struggling with memories of morally injurious events. He tells me he had been praying for a mental health co-leader for some time, so it was "perfect storm" timing to bring this program to the VA.

The program has been a work in progress, with ongoing quality improvement efforts and lots of veteran input. My colleague provided chaplain-driven materials as well as moral injury (MI) work being done elsewhere in the country. I combined this with my understanding of trauma, grief, and self-imposed guilt. I ventured into using metaphor, stories and drawing to help veterans develop personalized Impact Statements.

This new journey has allowed me to learn about unique aspects of Veteran trauma yet also to realize that the creative use of stories and art helps Veteran reduce symptoms of PTSD with purpose and meaning as they move forward. Dr. Chaplain Kerry Haynes and I have been leading a moral injury group for about a year and a half now. We have qualitative and quantitative data that speaks to the benefit of addressing moral injury. 

Since June 2019 we have been part of a nationally driven VA effort toward "integrated services" (clergy & mental health) for Veteran Moral Injury. After being invited to Washington with six VA Moral Injury teams, we now meet monthly and contribute to a Dynamic Diffusion (DDN)project. It is encouraging to see our work being disseminated to other VA's so that more Veterans can receive services for Moral Injury. We were able to "Skype-train" a new team at Tuscaloosa, and they have begun offering MI at a residential PTSD program.

We recently presented at the Texas Psychological Association. In the section on Client Creations, you will see Veteran pre-post drawings that depict perceived change. As part of the group, we use Part I (Trauma) and Part II (Hope and Healing) of Pernicano's Cracked Glass Bowl Story (adapted for Veteran population). 

All best, 

Dr. Pat

The opinions herein do not constitute Veterans Affairs official policy regarding treatment. 

                                                                       What is Moral Injury?

šA “betrayal” of what is “right” (Shay, 1994)

šThe action violates moral, religious or military standards (deeply held beliefs, values and expectations) (Litz et al., 2009).

It Can Be...

You as the “victim” OR you as the one at fault (survivor vs. perpetrator models)

šSomething you saw

šSomething you did alone or with others

šSomething you failed to do (you ignored something, did not report, or failed to do “enough”)

šCarrying dehumanizing memories

The person may have ignored something, did not report something, or failed to do “enough” by his/her standards.

7/25/18

We sometimes forget that adult clients, like children, often lack the words to describe their deepest pain and most hurtful experiences; metaphor, stories, art and play facilitate them doing so. In my recent work with veterans, both male and female, I have discovered many who also experienced trauma of some type prior to entering the military, particularly physical, emotional and / or sexual abuse. Some were raised in neglectful, domestically violent home environments, a life that laid the foundation for chronically high stress, hyper-vigilance, mistrust, avoidance, poor sexual choices and even acting out. Many entered the military to "escape" that difficult world, yet later experienced training or combat-related trauma, including what is referred to as MST (Military Sexual Trauma). 

I began using metaphor, stories and drawing in my work with veterans, to help them improve their quality of life through trauma-resolution, improved coping and positive relationships. As a group, they displayed a readiness to pursue change, and I started using the story The Cracked Glass Bowl to assess degree/intensity of trauma and to "jump start" the process of trauma recovery.  The results have been amazing, as the pre-post treatment drawings reflect qualitative changes in self-perception that parallel veteran scores on psychometric measures of somatic symptoms, anxiety and depression. I have shared some of these drawings in the Play Creations section of the website.  

All Best,

Dr. Pat