Trauma changes not only the way we think, but also the way our brains work.

“After combat, vets have to live with an altered neural network,” said Dr. Bessel van der Kolk, founder and medical director of the Trauma Center at the Justice Resource Institute in Massachusetts.

And that has profound implications for combat vets with PTSD. If neurological reasons prevent them from controlling some of the things they do, how can we hold them accountable? And what therapies work best for these damaged brains? We’ll look more closely at those two issues in subsequent blogs.

But first, let me tell you about a remarkable lecture that van der Kolk gave at the Center for Ethics and the Rule of Law at the University of Pennsylvania in Philadelphia last week.

Early in his career, one of van der Kolk’s patients told him that he had killed some Vietnamese children, shot an innocent farmer and raped a woman to avenge the deaths the previous day of all the members of his platoon, including his best friend. So van der Kolk used revenge killings as one example of moral injury at the PTSD conference.

“After something like that happens, vets don’t feel safe with themselves anymore,” he said. “And they may not feel safe being around their wife and kids.”

One problem is desensitization. As a soldier becomes numb to the chaos around him, he also loses his sense of compassion for others.

Even worse, it’s as though those traumas get stuck in a vet’s brain and he can’t get on with his life. “That’s because PTSD emerges from a part of the brain over which we have no control,” van der Kolk explained.

In the past few decades, neurologists have been able to use brain scans to determine how people’s brains respond to various stimuli and to memories. Van der Kolk showed several slides to illustrate how a traumatized brain operates differently from a so-called “normal” brain.

When a combat vet remembers traumatic events from his past, the prefrontal cortex of the brain – the center of rational thinking – shuts down. That makes it impossible to try to use logic to confront his memories, van der Kolk said.

In particular, one part of the left frontal lobe of the brain called the Broca’s area shuts down when confronted by trauma. “Without a functioning Broca’s area, you cannot put your thoughts and feelings into words,” van der Kolk said in his newest book, The Body Keeps the Score. “Our scans showed that Broca’s area went offline whenever a flashback was triggered….

“Under extreme conditions, people may scream obscenities, call for their mothers, howl in terror or simply shut down,” he wrote. “Victims of assaults and accidents sit mute and frozen in emergency rooms; traumatized children ‘lose their tongues’ and refuse to speak. Photographs of combat soldiers show hollow-eyed men staring mutely into a void.”

At the same time, the brain’s limbic system – the seat of emotions – is ramped up, and the amygdala sends out hormones and neurochemicals that drive up blood pressure, heart rate, and oxygen intake to ready the body for fight or flight.

There’s no known neural pathway to allow reason to moderate the emotions stemming from the limbic system, van der Kolk told the PTSD conference.

Trauma victims also have a harder time focusing because they’re distracted by everything around them.

“The left anterior cingulate filters out distractions around us,” said van der Kolk, “but trauma disables it. So traumatized people are unable to filter out outside influences, which makes it hard for them to learn new behaviors.”

Childhood trauma makes an adult more susceptible to being re-traumatized, he said. That’s especially troubling he added, because more than 12 million American women have been the victims of rape, with more than half of all rapes being forced upon girls younger than 15 years old. And each year, around 3 million children are abused and neglected, one third of whom so severely that local child protective services or the courts are required to take action.

“So if you want to eliminate PTSD in the military, only let people with perfectly safe childhoods serve in your army,” he added. “Of course, it would be a very small army.”

Van der Kolk closed his lecture by illustrating two dramatically different responses to the terror attacks of 9-11.

One was a 5-year-old child’s drawing of the plane slamming into the World Trade Center. It showed what looked to be a fireball explosion, people screaming and jumping out of the windows. It portrayed all the sights and sounds of the attack that had been registered by the limbic system.

But there was also one important element of rational thinking: the young artist had added a trampoline on the ground beside the World Trade Center so that the people who were jumping would not be hurt.

By contrast, the response from Washington, D.C., was completely limbic, van der Kolk said.

“After 9-11, the president said we’re going to bomb them alive or dead,” he said. “And that was totally a limbic response, not a rational one. Because our government operated on a limbic response instead of a rational one, more than 2,000 Iraqis who had nothing at all to do with 9-11 have been killed.”

So what kind of therapy does this neuroscientist favor?

“We need to bring that portion of the traumatized brain back online if we are to provide effective therapy for PTSD,” van der Kolk told the group.

In many ways, that involves the same techniques that a mother uses to comfort a frightened child: rocking, holding, soothing and singing. It’s also important that the vet, like the child, feel a sense of safety.

“Man is a social animal,” said Aristotle, and that concept is key to van der Kolk’s therapy. We connect with others by working in synchronicity, building rhythms that connect us with others, he said. That’s why breath exercises, chanting, martial arts like qigong, drumming, group singing and dancing are so important.

All rely on interpersonal rhythms, visceral awareness and vocal and facial communications that help shift people out of their fight-or-flight stages, reorganize their perception of danger, and increase their capacity to manage relationships, he said.

“Americans use alcohol and drugs to treat PTSD,” said van der Kolk. “But other cultures turn to dance, song, music and drumming. Yoga shows greater effectiveness than any pill you can take.”

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.’”

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.

I’ve been a little skeptical about using prolonged exposure therapy to treat post-traumatic stress disorder. Revisiting a trauma over and over again to become habituated to it seems fine in theory, but it has to be agony for vets already traumatized by those events.

So I was pleased to participate in a keynote panel at a conference, Preventing and Treating the Invisible Wounds of War: Combat Trauma and Psychological Injury, at the University of Pennsylvania Law School’s Center for Ethics and the Rule of Law. It featured Dr. Edna Foa, the professor of clinical psychology who invented the therapy.

PE therapy has been embraced by both military psychologists and the Veterans Administration, and Foa insisted that was because it is effective in treating PTSD. So far, about 1,300 mental health professionals have been trained in PE, she said.

She cited statistics showing that 1.8 percent of men in the civilian population have PTSD compared to 5.2 percent of the women, 9 percent of the Vietnam vets and 20 percent of the Iraqi/Afghan vets. There’s no real explanation for the difference between the two vets’ groups except that PTSD didn’t become a diagnosable disorder until 1980, five years after the war in Vietnam had come to an end.

She noted that the military suicide rate, which had traditionally been lower than the civilian rate, has nearly doubled during the Iraqi/Afghan war, exceeding the civilian rate in 2010. One service member kills himself nearly every day, she added, while male veterans are twice as likely to commit suicide as men in the general population

Then Foa addressed treatment, which she said is likely to be either prolonged exposure therapy (PE) or cognitive processing therapy (CPT) in the military and the VA.

PE involves repeated revisiting and recounting traumatic memories that are otherwise avoided because they cause so much pain. After remembering the traumas, there’s a period of processing them, including a recognition of changes of perception that might have occurred as a result. Therapists focus on fear and anxiety, but also on shame, guilt and anger. A second part of the treatment is approaching situations that the vet has been avoiding to show that they are safe in a post-combat world.

CPT involves changing a vet’s thinking in four major ways: learning about PTSD symptoms, becoming aware of thoughts and feelings, learning skills to help question or challenge feelings, and understanding changes of belief that commonly occur after undergoing trauma.

Both therapies may take 10 to 12 sessions – or more, depending on the severity and number of the traumas.

Foa cited one 2007 study of 284 female vets that showed PTSD severity dropped from 80 percent on the PCL scale to 50 percent after PE treatment. PCL is a 20-item, self-report list that measures the 20 symptoms of PTSD that are listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

She also cited a 2013 study of 1,931 vets being treated by the VA that showed 62.4 percent exhibited significant improvement of at least 10 points over their baseline PCL scores, with 49 percent dropping below the 50 PCL threshold for diagnosing PTSD.

Her conclusion was that PE and CPT are both more effective than just counseling, although she noted that a few studies have shown military personnel didn’t do as well.

“Some experts suggest that military traumas include more moral injuries than civilian traumas,” said one slide in her powerpoint. “Moral injury is associated with more severe PTSD and with suicide.”

In an aside, Foa told me she didn’t believe the concept of moral injury was a particularly useful one.

She also addressed the issue of inflicting too much emotional distress on patients in a paper published last year in the journal of Cognitive and Behavioral Practice.

“A concern that some clinicians may have with providing PE is patient overengagement, which is excessive emotional distress resulting from imaginal exposure,” she wrote. “Some patients may initially experience significant distress when reviewing their trauma narrative. Should overengagement occur, clinicians can modify exposure procedures to help patients remain grounded while describing their traumas.”

Nonetheless, she said patient dropout was only about 20 percent, about the same as other therapies.

More on this in our next blog.

I’m indebted to Jonathan Shay for showing me a new dimension of moral injury, or a wounded soul, as I prefer to call it.

For years, I’ve argued that the traditional definition of post-traumatic stress disorder only covers half the problem. It diagnoses and treats what others are trying to do to you: typically working very hard to maim or kill you. But the other half of PTSD isn’t recognized by the mental health community yet. That’s the moral injury: what you are doing to others, or what you have failed to do for others.

That might include shooting and killing a boy who looks like he’s carrying a grenade, but it turns out to be something totally innocent. Or it might be misreading the tactical situation and blundering into a fierce firefight in which a couple of your buddies were killed.

But I had dinner in Philadelphia a few nights ago with Shay, the retired VA psychiatrist who coined the term moral injury. We had both been invited to participate in a conference, Preventing and Treating the Invisible Wounds of War: Combat Trauma and Psychological Injury, at the University of Pennsylvania Law School’s Center for Ethics and the Rule of Law.

And Shay suggested a whole new aspect of moral injury that I’ve seen repeatedly … but never really recognized.

Shay argued that moral injury is also present when there has been a betrayal of what is right by a person in a position of legitimate authority in a high-stakes situation. “Both forms of moral injury impair the capacity for trust and elevate despair, suicidality and interpersonal violence,” he wrote in an article, “Moral Injury,” published last year in the journal of Psychoanalytic Psychology.

It’s a major step forward because it involves betrayal, something I’ve witnessed often over the years, but never really connected the dots. I’ve noticed that when patriotic soldiers sent into a battle begin to realize the conflict is unjust, they develop anger, bitterness and cynicism. They no longer trust authority in government or in their workplace. That often leaves them unemployed and homeless, with a marriage shattered beyond repair.

And it’s something that usually happens after the soldier returns home because military morality differs from civilian morality.

Take the lead driver in a military convoy who has been told to stop for nothing because it might be a trap leading to an ambush. He sees a small boy sitting in the road and hesitates because this seems so wrong, but then obeys the order and drives over the boy. In Iraq, he’s a good soldier, but at home, he’s a baby-killer.

Nancy Sherman, a philosopher and psychologist at Georgetown University, cited another example in an article, “Recovering Lost Goodness,” also published last year in the journal of Psychoanalytic Psychology.

She cites a civilian family in Iraq driving home from church which got caught in the crossfire of a U.S. attack on a high-value target. The father was killed instantly, and the mother and son were thrown from the car and also killed. A major who was first on the scene and gathered body parts was ordered to find the family and make amends.

However, Paul Bremer’s American occupation administration stymied the officer at every turn, convinced that the family members were insurgents. They sent him to deliver $750 to the family for damages, an insulting amount that the family rejected by throwing the bills on the floor and stalking out. The bodies sat in the heat for a month or more awaiting death certificates to authorize the burials. When the certificates came, they were marked in red ink “ENEMY.”

That moral injury can be devastating to a soldier, much more so than bullets and bombs.

“How does moral injury change someone?” asked Shay. “It deteriorates their character; their ideals, ambitions and attachments begin to change and shrink. Both flavors of moral injury impair and sometimes destroy the capacity for trust. When social trust is destroyed, it is replaced by the settled expectancy of harm, exploitation and humiliation from others.”

And that may be one of the reasons for the soaring suicide rates among veterans and active-duty service members.