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MoralInjuryRecognitionandCare

WilliamP.Nash,MDDirectorofPsychologicalHealthHQMCG-10ForcePreservation

william.p.nash@usmc.mil

CohenVeteransNetworkWebinar

27July2017

Disclaimer

• IreceiveroyaltiesfromGuilfordPressasaco-authorofAdaptiveDisclosure:ANewTreatmentforMilitaryTrauma,Loss,andMoralInjury

• AlltherecommendationsinvolvingclinicalmedicineinthisCMEactivityarebasedonevidencethatisacceptablewithintheprofessionofmedicineasadequatejustificationfortheirindicationsandcontraindicationsinthecareofpatients.

• Allscientificresearchreferredto,reportedorusedinsupportorjustificationofapatientcarerecommendationconformstothegenerallyacceptedstandardsofexperimentaldesign,datacollectionandanalysis.

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DisclosureStatement

• Theopinionsexpressedhereinarethoseoftheauthor,alone,anddonotnecessarilyrepresenttheofficialpositionsoftheU.S.MarineCorps,DepartmentoftheNavy,orDepartmentofDefense.

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MYTHOLOGYLITERATURE ARTRELIGION PHILOSOPHYTHEOLOGY HISTORY

SCIENCE

Science: The Newest Source of Nourishment for These Ancient Concepts

Sciencecanaddmuchvalue

Butonlyifsciencedoesn’tstealtheshow!

Simple Definitions

MoralInjury(MI):

Damagetoapersonresultingfromaviolentcontradictionofdeeplyheldmoralexpectations

MoralRepair:Rebuildingafteramoralinjury

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KeyComponentsofDefinition:

• Literaldamage• Tothewholeperson• Causedbya“violentcontradiction”• Of“moralexpectations”

SYNONYMSIntenseExtremeVehement

UncontrollableInordinateConsuming

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Generic Concept of Stress Injury

NormalStress• Youchooseit(largely)• Temporary• Reversible• Functioningismaintained• Integrityismaintained

StressInjury• Ithappenstoyou(largely)• Mayleaveascar• Cannotbeundone• Functioningisdiminished• Integrityisdiminished

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Nash,W.P.(2007).CombatStressAdaptationsandInjuries.InC.R.Figley&W.P.Nash(Eds.).CombatStressInjury:TheoryResearchandManagement. NewYork:Routledge;“CombatandOperationalStressControl”(MCRP6-11C/NTTP1-15M),2011.

StressContinuumREADY REACTING INJURED ILL

TotalFitness

Normalstress;“goodpain”

Stressinjury;“badpain”

Mental orphysicaldisorder

Fear Conditioning, Loss, and Moral Injurya

Fear Lossb MoralInjuryc

Triggering Event Actual or threatened death or serious

injury

Persistent separation from that which is cherished

Acts that violate deeply held moral

valuesRole at time of event Recipient or witness Recipient Perpetrator,

recipient, or witnessPredominant painful emotions

Terror, disgust, horror, helplessness

Sadness, longing Shame, guilt, anger, outrage

Re-experiencing YES YES YESAvoidance YES YES YESCognitive/mood changes YES YES YESPhysiological arousal YES YES YESWhat is lost? Safety Attachment TrustWhat is needed? Safety Relearn the world Forgiveness

a.Nashetal.,2011b.Prigersonetal.,2009c.Litzetal.,2009 6

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Moral Injury Events Scale (MIES)Subscales: Perpetration Other, Perp Self, Betrayal

Strongly Disagree

Moderately Disagree

Slightly Disagree

Slightly Agree

Moderately Agree

Strongly Agree

1. I saw things that were morally wrong. 1 2 3 4 5 6

2. I am troubled by having witnessed others' immoral acts. 1 2 3 4 5 6

3. I acted in ways that violated my own moral code or values. 1 2 3 4 5 6

4. I am troubled by having acted in ways that violated my own morals or values.

1 2 3 4 5 6

5. I violated my own morals by failing to do something that I felt I should have done.

1 2 3 4 5 6

6. I am troubled because I violated my morals by failing to do something I felt I should have done.

1 2 3 4 5 6

7. I feel betrayed by leaders who I once trusted. 1 2 3 4 5 6

8. I feel betrayed by fellow service members who I once trusted. 1 2 3 4 5 6

9. I feel betrayed by others outside the U.S. military who I once trusted. 1 2 3 4 5 6

Nash et al., 2013; Bryan et al., 2014; Bryan et al., 2015; 7

Moral Injury Event Exposure Best Predicted PTSD Symptom Group Membership in N = 208 OEF Marines

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* Only Moral Injury Events Scale scores were significantly different (p < .01) across all three PTSD symptom-level groups

Nash & Litz: Unpublished data from Marine Resiliency Study

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Pathways to PTSD in (N = 867) Combat Marines

9Jordan,Eisen,Bolton,Nash,&Litz(InPress).PsychTrauma

HOWTHEEVENTIS

EXPERIENCEDISKEY!

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Emotionalrepertoire

Relation-ships

Self-concept

Conceptoftheworld

Authorityover

oneself

Continuityovertime

What is damaged in Moral Injury?Could it be the same for Loss and Fear?

Identity. Core Self.

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Sin: Judeo-Christian concept of moral transgression

“Cain said to the Lord, ‘My punishment is greater than I can bear! Today you have driven me away from the soil, and I shall be hidden from your face; I shall be a fugitive and a wanderer on the earth, and anyone who meets me may kill me.’” (Emphases mine)

— Genesis 4:13-14 (NSV)

Sin: Judeo-Christian Root of MI

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Miasma: Ancient Greek concept of moral defilement or pollution, often resulting from unjust killing

“What can I do? Where can I hide from all this and not be found? What wings would take me high enough? How deep a hole would I have to dig? My shame for the evil I have done consumes me… I am soaked in blood-guilt, polluted, contagious… I am a pollutant, an offense to gods above.”(Emphases mine)

— Herakles in Euripedes’ Herakles (424 BCE)

Miasma: Greek Root of Moral Injury

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Facets of Moral Injury• Shame• Guilt• Anger• Contempt• Lossofhonor• Lossofjoy

• Lossoftrust• Severedties• Disconnection• Contamination• Unforgivability

Emotionalrepertoire

Relation-ships

Self-concept

Conceptoftheworld

Authorityover

oneself

Continuityovertime

Janoff-Bulman: Shattered Assumptions

14Janoff-Bulman(1992).NewYork:FreePress.

ThreeNecessary Assumptions• Theselfisworthy• Theworldisbenevolent• Theworldismeaningful

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Facets of Moral Injury• Shame• Guilt• Anger• Contempt• Lossofhonor• Lossofjoy

• Lossoftrust• Severedties• Disconnection• Contamination• Unforgivability

• “Iamnotgood”• “Ican’tbetrusted”• “Iamafailure”• “Iamhopeless”

• “ThereisnoGod”• “Thereisnogoodness”• “Lifehasnomeaning”• “Lifehasnopurpose”

Emotionalrepertoire

Relation-ships

Self-concept

Conceptoftheworld

Authorityover

oneself

Continuityovertime

Erik Erikson: “Identity Crisis”

16Erikson(1968).NewYork:BasicBooks.

‘Theterm“identitycrisis”wasfirstused,ifIremembercorrectly,foraspecificclinicalpurposeintheMt.ZionVeterans’RehabilitationClinicduringtheSecondWorldWar...Mostofourpatients,soweconcludedatthattime,hadneitherbeen“shellshocked”norbecomemalingerers,buthadthroughtheexigenciesofwarlostasenseofpersonalsamenessandhistoricalcontinuity.Theywereimpairedinthatcentralcontroloverthemselvesforwhich,inthepsychoanalyticscheme,onlythe“inneragency”oftheegocouldbeheldresponsible.Therefore,Ispokeofalossof“egoidentity.”’

Erikson,ErikH.(1994-05-17).Identity:YouthandCrisis(AustenRiggsMonograph)(KindleLocations142-147).W.W.Norton&Company.KindleEdition.

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Herman: “Complex PTSD”

17Herman(1992).NewYork:BasicBooks.

ComplexPTSD:Herman’sCriteria1. Prolongedsubjugationto

totalitariancontrol2. Alterationsinaffectregulation3. Alterationsinconsciousness4. Alterationsinself-perception5. Alterationsofperceptionof

perpetrator6. Alterationsinrelationswith

others7. Alterationsinsystemsof

meaning

Shay: Moral Injury & Undoing of Character

“However,IshallarguewhatI’vecometostronglybelievethroughmyworkwithVietnamveterans:thatmoralinjuryisanessentialpartofanycombattraumathatleadstolifelongpsychologicalinjury.Veteranscanusuallyrecoverfromhorror,fear,andgriefoncetheyreturntocivilianlife,solongas‘what’sright’hasnotalsobeenviolated.”Shay,Jonathan(1994).AchillesinVietnam:CombatTraumaandtheUndoingofCharacter(p.20).Scribner.KindleEdition.

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Facets of Moral Injury• Shame• Guilt• Anger• Contempt• Lossofhonor• Lossofjoy

• Lossoftrust• Severedties• Disconnection• Contamination• Unforgivability

• “Iamnotgood”• “Ican’tbetrusted”• “Iamafailure”• “Iamhopeless”

• “ThereisnoGod”• “Thereisnogoodness”• “Lifehasnomeaning”• “Lifehasnopurpose”

• Inabilitytocalmdown

• Lossofself-control

• Impulsivity• Outbursts• Unresponsive-ness

• Instability• Unpredictability

Emotionalrepertoire

Relation-ships

Self-concept

Conceptoftheworld

Authorityover

oneself

Continuityovertime

Targeting Self-Regulation:Restore Health to Brain and Body

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• Sleep!• Reducestressload• Stoppanicattacksorrageoutbursts

• Exercise• Nutrition• Prayer,meditation,yoga• Self-calming• Psychopharmacology

Negativemoral

emotions

Socialalienation

Damagedself

concept

Damagedconceptoftheworld

Lossofself-

regulation

Lossofcontinuityovertime

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Targeting Self-Concept:Competence and Self-Confidence

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• Competencebeforeconfidence

• Do,create,atone,become• Identifyandcorrectcognitive

distortions– Over-generalizations– Black-and-whitethinking

• Alignwithabenevolentmoralauthority

• Avoidhollowmoralreassurance

Negativemoral

emotions

Socialalienation

Damagedself

concept

Damagedconceptoftheworld

Lossofself-

regulation

Lossofcontinuityovertime

Targeting Concept of the World:Social Justice, Spirituality

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• Returntotheworld• Giveorseekamends• Seekorganizationsorentitiesthatstilldeserverespectandidealization

• Maketheworldabetterplace

• Religiouspractice• Art,journaling

Negativemoral

emotions

Socialalienation

Damagedself

conceptDamagedconceptoftheworld

Lossofself-

regulation

Lossofcontinuityovertime

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Targeting Moral Emotions:Mindfulness, Exposure Therapy

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• Learntotolerateintensenegativemoralemotions

• Mindfulnessmeditation• AcceptanceandCommitment

Therapy(ACT)

• AcceleratedResolutionTherapy(ART)?

• AdaptiveDisclosure*

• Practicepositivemoralemotionslikejoy andawe

Negativemoral

emotions

Socialalienation

Damagedself

concept

Damagedconceptoftheworld

Lossofself-

regulation

Lossofcontinuityovertime

*Litz,Lebowitz,Gray,&Nash(2015).AdaptiveDisclosure:ANewTreatmentforMilitaryTrauma,Loss,andMoralInjury.NewYork:GuilfordPress.

Targeting Social Alienation:Peers, Family, Community

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• Overcomebarrierstotrust

• Repairrelationships• Buildnewrelationships• Sharingstoriesinatrustingrelationship

• Mentorship• Peersupport• Mirroring

Negativemoral

emotions

Socialalienation

Damagedself

concept

Damagedconceptoftheworld

Lossofself-

regulation

Lossofcontinuityovertime

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