7 Tips to Address Moral Injury and Prevent it From Turning into PTSD

Welcome to this segment on moral injury and ptsd. In this segment we're going to define moral injury, what causes it, the effects of it, and current approaches to treating it. Moral injury is defined as the profound psychological distress that results from actions or the lack of actions which violate one's moral or ethical code. Morally injurious events can include acts of perpetration, acts of omission, or experiences of betrayal from leaders or trusted others. Moral injury is not a mental illness, although experiences of potentially morally injurious events can lead to negative thoughts about oneself or others, as well as deep feelings of shame, guilt or disgust, which can lead to the development of mental health problems. Now that was the overview introduction. Here are four different definitions of moral injury and I really want you to think about how civilians, law enforcement, military, health care workers, teachers, you know, pretty much anybody may have experienced these in the last 10 years. Drescher et al. In 2011 defined moral injury as a disruption in an individual's confidence and expectations about one's own or others motivation or capacity to behave in a just and ethical manner. In what ways have we seen or have people experienced in the past 10 years disruption of their confidence and expectations about their own motivation or capacity to behave in a just and ethical manner? Now that happens a lot. That's one of those. People are faced with choices and sometimes they make the wrong one. But also in what ways over the past 10 years have individuals confidence and expectations about other people's motivation or capacity to behave in a just and ethical manner? And, and Gwen says turn on the news and, and yes, unfortunately we are bombarded with examples of, of people, not only leaders, not only politicians, but other people, you know, even civilians who may not beh be behaving in a just and ethical manner. Unfortunately, you know, to kind of embrace the dialectics with this or whatever you want to say, what is reported on tv, what is reported on the news is only the stuff that they think you're going to watch. And they tend to put the worst stuff out there. You know, they report to you all the bad stuff that's going on, but they don't report the good stuff. Kind of like what happens with our, to our brain with PTSD when it notices is, is more tuned in to the bad stuff and just overlooks the good stuff. So it is important to recognize that there have been a lot of things and it's probably more prominent now than it was back in 1986 when we didn't have the Internet, when we didn't have 247 bombardment with news and information and stuff. And when there weren't so many channels that were competing for ratings with each other back when I was little. Okay, I know I sound like an old fogey now, but back when I was little we had three channels and, and that was it, you know, and when the news was off, the news was off and unless you went and read the paper, that was about the only other thing. In 2009, Litz et al Further described moral injury as the inability to context, contextualize or justify personal actions or the actions of others and this unsuccessful accommodation of these experiences into pre existing moral schemas. So this is where the shoulds come in. The inability to conduct, contextualize or justify what I did based on pre existing moral schema. I can't look at myself in the mirror and go yeah, I did the right thing. I look at myself in the mirror and go yeah, I'm not, I'm just not sure at best or I am disgusted and self loathing or the inability to contextualize or justify the actions of others into pre existing moral schemas. When you're looking at what others have done and, and you say to yourself, how in the world could one person do that to somebody else or somebody's else? It's just beyond our understanding. And that can lead to a sense of disgust and anger and irritability and unfortunately sometimes overgeneralization where we start thinking that all people in a particular category may be untrustworthy and amoral. Shea 2014 emphasizes leadership failure and the betrayal of what's racist right by a person who holds a legitimate authority in a high stakes situation. Now for law enforcement, this could be the captain or the lieutenant. In the military it could be the captain or the lieutenant. In hospitals it could be the attending physician. You know, you can see where there are in, in where we work, you know, it could be your boss who holds a legitimate authority and could fire you if you don't what they tell you to do. What really occurs here is when the person feels betrayed, they're looking at it going this is not the right thing to do. And the higher ups are saying I don't care, do it anyway. And then in Silver in 2011 talks about a deep soul wound that pierces a person's identity, sense of morality and relationship to society. So if they do may be something that they look at themselves and go, I can't look at myself in the same way after doing this. If somebody else does it, they may say I can't look at others in the same way, knowing that there are people out there who could do this. So there are a lot of nuances to moral injury. And ultimately, it seems to have a lot to do, you know, obviously, with what you feel you can control and what you feel is just and good in the world and whether you can trust yourself or trust other people. So it goes back to that sense of safety and empowerment. In what ways has social media potentially confounded moral injury? You know, back when I was younger, we didn't have social media. And when people talk to each other, they tend to be more. I don't know if politically correct or compassionate. Compassionate is probably a better word in what they say and what they don't say. And there's a phenomenon in social media called disinhibition. And when people are typing, even if their icon, you know, next to their profile is. Is them or whatever, people tend to say things online that they would never say to another human being. I mean, I was personally. I'll. I guess I'll share. I was personally disgusted at, during, during the last election at all of the name calling on, you know, I was just. And it wasn't just politicians. It was people calling other people names and being very denigrating to one another. And it was confusing to me why people that, you know, probably normally were very compassionate people, I would think in, in real life, you know, they get online and they can just be so hurtful and. And that was very confusing to me. But disinhibition certainly can compound things. The cancel culture, as Kathy points out, can contribute to moral injury because you have one side believing in something and you have another side believing in something else and saying, well, you can't. You can't believe what you believe. And people are canceling each other, saying that, you know, your beliefs do not fit into my schema and so you can't have them. And it goes, you know, it's not one way with any argument. It seems like cancel culture is, you know, very. What's the word I'm looking for? Pervasive. But yes, we have in a lot of ways lost the golden rule, as Gwen says, because we don't stop to think about the impact of what we're saying and how it might affect people. So take them, take a moment and go on Twitter and just read some of the comments. I don't care, you know, whose comments, but read comments and think to yourself, is this something that a person would actually say to somebody else to their face? And there has been a lot of discussion about the term narcissism in online. I mean, if you go on YouTube, there are thousands of videos about narcissism. Maybe not thousands, hundreds at least. But when we're looking at narcissism, really, a lot of what it seems like we're talking about right now is people's inability or unwillingness to take another's perspective. H Where does that sound familiar from? So I have to wonder, why is it that people are in uncle unable or unwilling to take others perspective? Could it be aces? Certainly. But it could also be the way we communicate now, because texting somebody or tweeting at them doesn't force you to have empathy. It doesn't force you to take their perspective. You're just. You can talk at them. You're not talking with them anymore. You're talking at them. We talk at each other, it appears to me. But. So I think social media doesn't have to be confounding, but the way it's used a lot, I think it can be. Studies have shown moral injury among law enforcement officers and civilians experiencing community violence. Okay, so going back to those definitions, Law enforcement officers and civilians seeing other people doing things to each other that you can't fathom that one person would do to another. You know, and sometimes moral injury and PTSD and trauma overlap. They don't necessarily. You know, not everything that causes moral injury causes ptsd. But it is important to recognize that a little piece of us is affected, or maybe a bigger piece of us is affected every time we see something that. Or see somebody engage in a behavior that goes against our moral compass or that we. When we engage in a behavior that goes against our moral compass. Moral injury among health care workers or even legal guardians may occur if they have to make difficult decisions related to life and death or resource allocation. During pandemics, some healthcare workers may feel like they must choose between caring for infectious patients and keeping their patients safe. That we heard that repeatedly over the past year. And this was definitely something that weighed heavily on. On healthcare workers. And. And the term health care needs to be expanded because there were a lot of us who work in residential settings and things that, you know, had to show up for work. You know, it wasn't like we could just discharge everybody from crisis stabilization and say, hey, you know, I really want to keep my family safe, so you're on your own. That's not what we can do. So you're in a moral quandary. Thinking back to the Hans dilemma, if you remember the Kohlberg dilemma, Where Hans's wife is really, really sick and he has to make a choice. He can either steal the medication because he can't afford it and save her life, or he can obey the law and let her die because he can't afford the meds. So that's really what we're talking about with moral injury. I mean, there are other examples, but when they are present, when people are present for end of life scenarios that are counter to their beliefs about how people should die, such as patients dying without loved ones present, continuing to live despite horrific pain, or having to withdraw life support. So, you know, depending on people's beliefs about suicide, assisted suicide, and you know, that whole realm in there, it's going to affect different people differently. If you have a loved one who's in a coma and their advance directive says to withdraw life support or whatever, I don't know how that exactly works, but I know there are times when people are expected to withdraw life support from their loved one. And, and you know, that is a really hard choice for I think just about everybody to make and to integrate into their, into their schema. We, my point with this is we don't want to limit ourselves to moral injury to just one group of people like the military, which is kind of where this started. We want to recognize that anytime that you are faced with, or people are faced with two, basically two bad decisions or two good decisions, and they have to, they can only choose one, however you want to look at may cause them a lot of distress. Second guessing themselves, wondering if they made the right decision. Or if they're told to make one decision and they think the other decision is correct and they make the decision they're told to make than feeling disgusted with themselves. So there's a lot of nuances in moral injury. Morally injurious experiences and the resulting guilt, shame or anger may contribute to stress reactions such as changes in sleep, significant and persistent negative changes in behavior or habits, difficulty concentrating, increases in mistakes, isolation, compulsive or addictive behaviors, and a weakened sense of empathy or compassion. Now that last one was one that surprised me, but I guess I can understand. If your moral injury comes from seeing people do things that you wouldn't expect one person could do to another. Or your moral injury comes from being betrayed from, you know, somebody that you had faith in, then I might be able to see how it could become more difficult to have empathy and compassion for others because you've been disappointed or disillusioned so many times. So we do want to consider how these Experiences impact us. And I agree, Gwen. That's a great way to put it. This lack of or unwillingness or inability to experience empathy and compassion may be a way to deaden the pain of betrayal, because it's hard to be empathetic and see these things going on and see people not doing anything to stop them and, you know, feel okay and, and exist. If the morally injurious situation was also a traumatic event, it can lead to symptoms of ptsd. But we do want to recognize if people are experiencing moral injury. You know, let's think ER nurses, okay, if they're experiencing moral injuries, then they're having symptoms like changes in sleep. And we know that that's going to make them more at risk for ptsd. And then something happens in the ER that is traumatic, bada boom, you know, then they're at greater risk of developing PTSD as a result. Think about the ways these behaviors impact the loved ones and the children of the people who have experienced moral injury. How does it affect them? How does it affect their ability to create secure attachments and, you know, all that stuff. If they are not sleeping well, if they have negative changes in behavior, difficulty concentrating, they're isolating because they just can't deal with input and, or engaging in convulsive or addictive behaviors and having a weakened sense of empathy and compassion. Now, sometimes that weakened sense of empathy and compassion is directed toward the group that you identify the offender with, but sometimes it's just with everybody at a certain point. Sometimes the moral injury can be so exhausting that it's just. It's too much to empathize, it's too much to have compassion because it just hurts too much. Welcome to the All CEU's education channel where you will find long form counselor education training videos as well as shorter overview videos geared toward the general public. We have over 900 videos, so using the search function that is underneath the subscribe button on our homepage can help you find the videos that you really want to watch. You can also find an alphabetized set of some of my most popular playlists@allce.com YouTube playlists. I absolutely love hearing from you, so keep those comments coming. We actually do read all of them and try to respond within a few days. Have a fabulous day and don't forget to click subscribe and the bell if you haven't already, so you can be notified when I release new videos. The oh, those awful, awful. They're not the Humane Society. The ones. What. Who is? Who does the commercials with the Animals that are abused. Anyway, I can hear the, Hear the song. PETA is one of them. Aspca. Thank you. Those commercials, I have to turn them off. They are just too overwhelming for me and to. To see, to deal with. So that's another example of how we're kind of bombarded. When I see things like that, I'm like, how can a human being do something like that to this, this sweet little animal? You know, it's just. It bewilders me and it does tend to make me more cynical of things. So I. I try to distance myself from some of that propaganda, so to speak. And I know they're doing it to raise money and, and all that kind of stuff, but it's. It's too much. I mean, I can't. I can't do it. So. It is important to recognize that sometimes these moral injuries do come from the media, do come from things that you wouldn't really expect. It's not like something that you were directly involved in. So risk factors for moral injury. If leaders are perceived to not take responsibility for the events and are unsupportive of those that they lead. Have you experienced this yourself at work? You don't have to say yes or no. I'm just rhetorical there. That one's rhetorical. Have you, you know, experienced this at work? Have you experienced this in your life where leaders, you know, government, politicians, law enforcement, whomever, you know, somebody who has power over you, were involved in something and didn't take responsibility? Loss of life to a vulnerable, vulnerable person, and I would add, or animal, can also contribute to moral injury. If an elderly person or a person with a disability or a child is killed, then it can be more difficult. Likewise, during the pandemic, when vulnerable people were dying, it was really hard for and, and morally injurious to a lot of medical personnel who felt like they should have been able to. Should have been able to save those people. They should have been able to do something. They should have been able to prevent it. And so there's a lot of shoulds involved in moral injury too. If people feel unaware or unprepared for the emotional or psychological consequences of their decisions. Removing life support is an example of this. If the event occurs concurrently with exposure to other traumatic events, if there's a lack of social support following this injurious event, and also if somebody has obsessive compulsive personality disorder, they may be at greater risk for moral injury because they tend to be less cognitively flexible when it comes to issues of morality. Specifically if they have the symptoms of being over conscientious, scrupulous and inflexible about matters of morality, ethics or values. When one of those lines gets crossed, it's hard for them to process that and it certainly doesn't get assimilated. And if they are reluctant to delegate tasks or work with others unless others submit exactly to the person's way of doing things. So if they tend to be very rigid and controlling and other people betray them, it can be extremely stressful, traumatic for the person that we do want to pay attention, that certain personality characteristics can make people more, more at risk for moral injury. So how do we address it? Currently there are no best practices. Well, thanks a lot, doc. In addition, there is conflicting evidence about prolonged exposure therapy in terms of whether it is harmful or helpful in addressing moral injury. It's important to be alert when you're working with people who have moral injury to if they're projecting their disgust onto you, if they are thinking, asking am I being judged? Is my therapist disgusted with me? Is this too much for my therapist to handle? And those are not uncommon thoughts. A lot of people who've gone through traumas have these thoughts, let alone moral injury. They also have these thoughts. And, and so it's important for us to put this out, get this out on the table, so to speak, because a lot of times the client is, has already been judging themselves, they're already disgusted with themselves and they already feel overwhelmed by it. So they're projecting all of that onto the therapist going I wonder if that person feels the same way I do. And we need to talk about that. We need to be authentic as possible. Moral injury may lead patients to believe that they do not deserve to feel better, which could negatively affect how much they engage in and comply with treatment. Survivor guilt is big, but also just people who, who feel like I did a bad thing and I don't deserve, I don't deserve to ever feel happy again. So we need to explore those thoughts with them. Acceptance and commitment therapy has actually been adapted for moral injury. And there's a 12 session group protocol focusing on helping patients live in accordance with their values, identifying their rich and meaningful life, being mindfully aware of the present, accepting it non judgmentally and, and you know, figuring out what are the best thoughts, behaviors and actions that I can take in order to move me towards my goals of a meaningful life. Adaptive disclosure is a 12 session individual treatment that helps patients by using an imaginary dialogue with a compassionate moral authority, by appointing blame, making amends and in some versions, self compassion and mindfulness meditations, the person works through the morally injurious event. Self care is also important for addressing moral injury. When we are exhausted, when we are not sleeping well, when we're worn down, when we are, you know, not paying attention to those other aspects of our life, we can be more vulnerable. Cognitive processing therapy has also been found to be effective. And you can find the A guide for Cognitive Processing Therapy online. Cognitive processing therapy with veterans if you want to look at exactly what's involved in it. There's also an app by the national center for telehealth and Technology called the Provider Resilience App, which can be helpful in. As a resource for behavioral health and health professionals that are often in situations that could lead to burnout or moral injury. And the Skills for Psychological Recovery Manual is, I believe it's 158 pages. It's a long old manual, but it's basically a spin on psychological first aid that was put out, I think, by the va. Let me look at the. Yeah, it was put out by the VA that can provide tools that can be used in the aftermath of a stressful situation. You know, maybe in a hospital, resources had to be allocated one way because there was this, you know, huge catastrophic event, and it may have caused moral injury to certain people who thought it should. Should have been handled differently, you know, whatever. But the Skills for Psychological Recovery Manual is an interesting approach at identifying potential risk factors and things that need to be worked through in order to help people assimilate what happened. Moral resilience helps reduce feelings of being deficient, neglectful, or weak by helping the person. So acceptance of commitment therapy also can be effective at helping with developing moral resistance, having the courage and confidence to confront distressful situations by following values and beliefs while maintaining perspective. So we can help people explore the situation and how they acted in accordance with their values and beliefs to the best of their ability at that point in time. You know, if they were told to do something and they didn't agree with it, or they had to make a choice that they didn't want to make, but they made it anyway, for what reasons, what reasoning, what reasoning guided that decision making, what courage enabled them to make that decision? And in what way is that decision actually in a line with your morals and values? For example, removing life support from somebody who's, you know, advanced directive was to have the life support removed. Okay, so that's a. More. That's a big moral decision for people. And maybe the person didn't. Doesn't believe in suicide, doesn't believe in assisted suicide, but they did it anyway. So what rationale did they use that helped them make that decision? Recognize what and is, is and is not within one's control. You know, in that particular case, you know, healing this person is not in your control. Adhering to their wishes, that is within your control. And resisting the presumption that there's only one way to consider one's moral obligations in terms of a end of life decisions. You know, moral obligations could be to help the person be as comfortable as possible versus, you know, insisting that they continue to live in agony. You know, if they're in a lot of agony. You know, there are, there are different moral issues. And looking at what was the moral principle that supported your decision? Why did you do it? Because it was right. And this goes to kind of what Teal was referring to with Kohlberg's stages of moral development. Did you do it because it benefited you? Did you do it because it was right for the person? Did you do it because it was right for. For society as a whole? What was it that motivated your ultimate decision? Moral injury is defined as the profound psychological distress that results from actions or the lack of them which violate one's moral or ethical code. And this can be again, actions that you do or don't do or, or you see others do or fail to do. There are currently no best practices, as this is a relatively recent conceptualized syndrome. Although acceptance and commitment therapy may be effective at increasing moral resistance resilience. So what questions do you have about moral injury?