Psychiatry & Psychotherapy Podcast - Moral Injury

Episode Date: May 6, 2022

In this episode of the podcast, we interview Dr. Herbert Harman, a psychiatrist who works as a practice line director for Vituity. We will be discussing "moral injury", an emerging term defined as "perpetuating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations" (Griffin et al., 2019). Moral injury is similar to PTSD but has distinct differences. While it is often seen in military settings, various front-line careers also present opportunities for moral injury, including psychiatry.  By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CME while listening to this podcast. Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is email to you in seconds. Before we start the show, we'd like to announce conflicts of interest. Neither Dr. Pudor nor Dr. Harmon have any conflicts of interest to announce. So let's begin the show.

All right, welcome back to the podcast. I am joined today with Dr. Herbert Harmon. He is a psychiatrist who works for Vituity as the practice line director for acute psychiatry. It is a national partnership of physicians that offers acute care services, including the specialty of psychiatry. He went to medical school at the University of Virginia and residency at Western Psychiatric Clinic in Pittsburgh. He was commissioned by the Air Force and deployed through the Army in Afghanistan. And we will be talking today about moral injury, which is perpetuating, failing to prevent, bearing witness to, or learning about acts that transgress

deeply held moral beliefs and expectations. It is similar to PTSD. It is similar to PTSD. but different. We'll be talking about in the context of the military, but also this extends to various fields where you're on the front line, including probably psychiatry, and we'll talk a little bit about that. We'll also talk about identity and how identity and narrative and the stories that we tell ourselves kind of intertwined into moral injury and how it's important to have a narrative that we can improve and get better and progress. And we'll talk about that as well. So, Dr. Harmon, welcome. Yeah, thanks so much.

So he goes into hospitals, fines, contracts for groups of physicians. That's part of his job. He's also a psychiatrist, also worked in the military, right, overseas, or where were you when you, and how many years did you spend there? Correct.

So I had an active duty commission actually still do with the United States Air Force. was on active duty for four years the entire time stationed at McGuire Air Force Base in New Jersey and had one deployment I was called what's ILO task in lieu of the army had churned through all of their psychiatrists and they started barring folks so I got attached to the 82nd Airborne and went down to Fort Hood in Texas and did all my combat skills training and then went with the infantry to Afghanistan for the better part of a year, gone from home for about eight and a half months total, actually.

That's brutal. Yeah, it was interesting. I learned a lot, so I guess that's why we're talking. Yeah, so we were having a conversation a couple weeks ago, and I was like, I've really got to bring you on to the podcast and have this conversation, like, kind of out loud, because I feel like it would be helpful. We're going to be talking about moral injury,

which I feel like as a provider, once you really understand what moral injury is, you're going to, and it's different than PTSD, it overlaps a little bit, but it's different. Once you really understand what moral injury is, I think you're going to better understand how to talk to vets, how to talk to people who have been, for example, the police, maybe even on the front lines of like CPS. So I think understanding the concept of moral injury will allow, you to know how to ask the right questions, listen more empathically, and help these people overcome, right? And so we're going to be talking about that. We're going to be talking about

identity, you know, respecting, you know, the work that was done in the military that these vets did. So Dr. Hartman can tell me more about what that means. And maybe when you know that you know that you probably shouldn't be working at the VA or when you shouldn't be working with this population. And then we'll talk about how you really want to get people better. And I think we really resonate together because I run this program and we always see these people that get stuck in this idea of illness and I am illness and I am disabled and I am chronically this way. and the narrative of that is in and of itself toxic. It has secondary gains.

There's reasons why they want that, but it's toxic to the person psychologically to believe that does something to them that then doesn't allow them to thrive. So, yeah, shall we start with moral injury and talk about what that is? Sure. It's interesting to try,

and describe what moral injury is. Because as we've learned from reviewing some of the literature, it's sort of all over the map. And most of the publications that seem really well written have a little section somewhere that says, yeah, we're still trying to get a consensus or define this. But in short, it is how a lot of folks in clinical care and in research are describing a reaction to events

that may or may not be under. understood as traumatic events in which an individual's identity and sense of justice or a sense of purpose is shattered by the event. And it's usually an event where something is very personal, very visceral. So the easy to describe circumstance for a moral injury would be a deployment where there's a commanding officer who does something unethical or immoral and the people under that person have to then do something that they feel is unethical and moral, and they follow through with that thing, whether it's hurting someone or violating some sort of ethical code or violating a religious

identity or spiritual identity that they have, and then emerging from that and having a set of symptoms that can overlap with PTSD, but look very different when you're paying attention. And what I mean by that is there's not so much the startle response or the dissociative episodes or the re-experiencing. It's more self-loathing, depression, isolation, avoidance. And a lot of it can be found in a narrative that a person has about what they're experiencing, as they're describing. I don't know who I am anymore. And I have a lot of lack of motivation for self-care and for care of care of others feeling like, Like, you know, I don't, I'm not worthy of caring for my kids and my wife anymore.

You know, so again, overlapping with depression, not necessarily meeting criteria for major depressive disorder, though. So I think that's part of what makes it so hard. It doesn't, it doesn't fit nicely in any of our boxes. Yep. So there's this potentially morally injurious event. And you mentioned one type. There's, in that review you gave me, there's two types. there's the betrayal-based event, which is like betrayal by a leader, a trusted authority,

bringing you into something, making you guys do something, maybe doing something to you. There's that. And then there's the perpetuation-based event, which is why you're like perpetuating or witnessing actions that violates one's core beliefs. So you're violating your own values or rejecting previously held religious beliefs. And so you have this event. So it's different than PTSD, which is like a near-death experience, right? And there could be also mixed in, of course, in war near-death experiences.

But this seems to me like when I sat with vets for a long time and you're trying to get to like what's really going on, this is the story that they don't tell you. Right. They tell you like a narrative that they've told a bunch of people often. and it's like when they're telling it to you, there's not a lot of affect on their face. They're not experiencing dissociation or anger or sadness. But then when you get to this event, it's like they can't even go there.

They can't even talk about it. Yeah, no, absolutely. And the perpetuation that you're talking about most commonly, and the easiest to visualize, understand, and describe is just the act of killing someone. And so for many veterans who have grown up in the United States, very, you know, I'll just use the word typical. I don't like that word, but I'm failing to find a better word in this moment. But typical experience, you know, going to elementary school and you've got one or two parents who care about you and neighbors and you play sports and you learn about democracy and nationalism and whatever.

And then you find yourself at close range killing another human being. and coming home wondering, was that necessary? And is this who I am? And the worst-case scenario for folks being fully enmeshed in the experience to the point where it's an enjoyable experience to be in that warrior moment. And then having to recognize that this is part of who I am. And I have to confront that now.

I now know that it's possible for me to enjoy killing people. And that is not uncommon, right? So if you're a warrior and you're at war, I mean, we've all seen, if you've never been deployed to a wartime environment, if you've ever watched a movie like Private Ryan, you can understand, you know, if you've got your group of guys and you're fighting another group and you survive and you save your buddies, that's exhilarating probably. That doesn't mean you're a bad person through the lens of a civilian. But if it's you, that's a very different experience because it's you. And, you know, what do you now think about yourself? And how do you reconcile that? So I first really had began to appreciate what we're talking about when I was, not while I was deployed, but instead while I was stateside, but before and after my deployment, we were stationed near Philadelphia and large recruiting centers in Philly.

And this was, I was active from 05 to 09. So if you recall, the intensity of fighting, you know, was pretty high. And we had already experienced, you know, many thousands of folks redeployed. So the offensive in 2003 and Iraq was long over, but the after effects were there. So for Marines, after they serve a number of, you know, combat deployments, they usually get sent to recruit. And so I had these men who had multiple deployments and had killed a lot of people who were now going into high schools and recruiting young men and then sitting down with their families and explaining why this was the best option. And they were a mess. And that all came out.

And there was a strength that I had from after deployment. that allowed me to connect with them. And the strength is not inherent to me. It was just simply the fact that I'd been there. So they gave themselves permission to talk about these things with me, especially when I came home. You know, beforehand, they would talk to me a little bit.

But once I got back, it was a completely different experience. And I got the full story, or at least what I perceived to be the full story. And, you know, PTSD was there. but it was mostly a combination of depression and identity, which we're now, you know, as we're talking about, you know, defining as moral injury.

Yeah, yeah. And so, you know, just to reiterate, in PTSD, you'll get the start or reflex, the flashbacks, the nightmares, the insomnia, but in the moral injury, what they found is that there is an increased risk of mental disorder, suicidal ideation, attempts. guilt, shame, especially if there was perpetration, anger, especially if there was betrayal. There's Anhedonia. You feel socially alienated. Like you're saying, like you don't feel like someone who's a civilian would ever really understand what you're going through. You'll feel

some resentment maybe due to feeling misunderstood by civilians, which increases suicidal risk as well. There's depression. There's, you know, self-reesome. self-deprecation, you feel social isolation maybe, maybe act out a little bit, substance use, destructive behavior, aggression towards others. There's mixed studies on that piece in particular. And then there's also like religious struggles. You know, I feel abandoned by God. I'm doubting my beliefs. I'm questioning my purpose. I'm perceiving one's action. You know, I'm perceiving my own actions as a violation of my religious spiritual ethic. I can I am unforgivable.

So you're back from deployment, you're meeting with these people, you're trying to help them through their own moral injuries that they've experienced. Yeah, that seems very gripping me. Tell me, are any stories coming to your mind on how you, in particular or what that was like? Yeah, absolutely. I can think of two or three cases I probably remember forever. I was an officer who had led a group, you know, moving in in 2003. And one of the Iraqi fighters that end up, you know, taken by our U.S. forces and interviewed and just make sure that, you know, like, hey, this is not someone who's intending to function

as an insurgent and they got to know most of these guys pretty quickly and realized, you know, okay, well, we're just two humans representing different leaders and organizations and identified the folks who said, yeah, you know, we want to build a better country, we want to work with you, and then befriended them, right? And then set up, you know, help set up the Iraqi military. And then short order people coming in from other countries, establishing an insurgency. Our U.S. officers had to fight alongside these guys that they had just months before been, you know, opposing forces. And then they became like battle buddies.

So U.S. military and Iraqi military becoming close friends, getting to know each other, learning about each other's families and kids. And then the U.S. officer says, I'm going to go left, you go right. The guy goes right and he gets killed. And there was something about that dynamic for this one officer that I have in mind that just was life-shattering for him. He had somehow reconciled everything that had happened with the initial push in his own mind to allow him to recover and move forward. But then he formed an alliance. Basically, I think it was we talked in the literature about making amends, how making amends can really help people. There's a whole process for that in certain kinds of psychotherapy.

And then when that was shattered by what he probably, what he felt like was a betrayal, you know, of him, you know, he betrayed this person that he had brought him to the fold. How did he betray him or what was the, well, by putting, you know, by sending him into battle, you know, by making operational decisions that ultimately led to his death. Oh, okay, yeah. Yeah. So they were still fighting on the same side.

But, you know, as in you're making decisions and this is your person. Right. You know, this is your, this is your, you feel responsible. You feel morally obligated to keep this person as safe as possible. And then something bad happens. Right. Right. And then the other cases I can think of, and one in particular,

I was a Marine who just, from what I could gather, just a really emotional, very sweet human being, stateside growing up. Felt a sense of honor and duty, you know, very patriotic. And had just killed a number of people at very close range was apparently a very good, you know, fighter. And I really believed in what he was doing.

And over time, it's just as the war drug on, just became less and less enchanted with the idea that he was making a difference. difference or anything that he did made a difference. And all that he was left with was, you know, the U.S. government's very good at helping me kill people. And that's what I do. And that's who I am. And that's never been who I wanted to be or what I'm about. And when I would chat with them before or after our, you know, individual sessions, you know, just kind of helping people feel comfortable coming into the room. How's your week? You know, you could tell.

you could get experience all the social reciprocity and all the little things that he would say and get some sense for what what he was like if you were his neighbor and how he came across to me socially was a complete opposite of the narrative for what he was and who what he had to do to survive on deployments and it kind of he was like empty inside you know other than carrying this tremendous weight as he was trying to figure out, okay, well, who am I now? How do I understand who I am now? And what does that mean about my capacity to be a loving spouse and a parent and a person who cares about his society and being a U.S. citizen and everything? Everything else was a mess. The one thing he knew was that he was really good at, you know, fighting.

And so he had to try to figure out what to do with that. Yeah. So there's that kind of like identity, like my narrative of myself has shifted and it's kind of like the disenchantment. I see that with psychiatrists as well sometimes they or therapists. It's like they just get, it's like when we get tired, when we get burned out. I don't know. It's probably not a good parallel, but I don't know. I think it is. Okay. I think it is. It's like, okay. Like it moves from like, I feel like the humanitarian aspect of the work that we do is really meaningful, right? We're helping people. But yeah, we can get disenfranchised and kind of get where we can be like, okay, it's just a job. It's just money coming in. It's just to provide. Is that what you're thinking? Well, I think we work in, you know, everyone says, oh, fix the U.S. healthcare system. I laugh and say, if there was a system, we can. fix it, right? And so we're sort of bouncing around between healthcare systems, insurance companies, global economies, you know, state governments, federal government regulations and trying to do the best we can. And so, for instance, when you said that, the first thing that came to mind for me was

just what it feels like to stand in an emergency room and see people flooding in desperate for anything, help, right? In the emergency room, it's very defined. There's things that the ER can and can't do. And most of your needs can't be met in an ER. The emergency need can be met. And so you talk in your podcast often about the value of the IOP type services that you've been able to deliver in your career. And I'm a huge fan of them because I think there's so helpful and there needs to be way more of it. And also true for most people on, say, for instance, Medicaid, that's not a possibility. Right. So when I see people on the emergency, room and they don't have an emergency medical condition that requires emergency intervention,

but they would definitely benefit from an IOP and PHP. I'm getting paid to say, hey, what you need is this thing, and I know this thing doesn't exist. And so I'm trying to say, okay, well, let's patch together what else could look like that. And you know deep down, like, you can't really replicate it without the thing. And you're facilitating a dischargeer. to facilitate discharge and you're getting paid for it. And you kind of still have to go home and look at yourself in a mirror and go, wow, like, how did I end up here?

And it's not like things would be better if I wasn't there. And it's not like things would be better if I made a different decision, right? You know, because I can't justify admitting people who don't mean criteria. They could get assaulted or disease on the inpatient unit. There's no, you know, virtue, there's no heroism and admitting someone who doesn't need to be there, nor is their heroism and, you know, staying home and saying, well, that's somebody else's problem to manage. But we're left, I think, often churning in systems where we came into medicine hoping that we were going to do something very specific and we're always going to, you

know, deliver something great. And when you have a serious, when it's pretty normal to go into a shift and see all this suffering and, and feel sometimes, Like you're just kind of a cog, as they say, you know, in the wheel. I think you can start to experience things like that. Yeah. I think that's why I enjoy doing therapy, individual therapy, although it's, you know, as a psychiatrist, it probably would be more, you know, economical to just do more med management and have someone else do the therapy.

But I love being a part of the process, you know. of the therapy itself. Okay, so we're getting back to this person that you, I want out with this story of this officer who sent in the Iraqi. How did you help him? Or do you feel like you were able to help him? Or how did the group help him? Yeah. So he had a number of resources, not least of important, was a case manager who would check in on him frequently. and make sure that any kind of appointments he had were, you know, reminding him you have an appointment with your therapist tomorrow to, you know,

you have an appointment for your lower back pain next Wednesday. And so he was on medication for depression. I don't remember. It's too far gone to remember what or any of the specifics probably don't really matter here. But I was there to help make sure that anything that, any medication he was going to be on. actually made sense. I think folks with moral injury,

it's easy. If they're drifting in the community, they're going to come into you possibly on a bunch of benzodiazepiates and stimulants. So for folks who are listening, I mean to say benzodiazepines, which are sedatives, which can be abused. And although they might facilitate a little bit of sleep,

actually disrupt deep sleep wave architecture, you know, opiates, opioids, things like oxycodone for chronic pain, commonly for acute pain or cancer, but if you're listening to popular press or you work in medicine, you know there's an epidemic of overprescribed opiates. At the time, that was still going on, you know, way worse than it is now. And stimulants, which, you know, if you've been through trauma, you're not concentrating, or at least you appear as if you're not concentrating to most observers. You can easily find yourself, you know, talk somebody into believing that you have

adult onset, attention deficit or something like that. So I think it's a pretty common experience for psychiatrists to have folks land in their office on some combination of these three drugs. So I think a lot of what I did was for these guys to make sure, like, either they're not on these drugs or if they are on them, I'm helping them get off. and we'll go ahead and try SSRIs or mood stabilizers, SSRIs, higher doses, mood stabilizers, average doses, anything that is going to make sense for treating PTSD and depression

and not put them at risk for getting worse instead of better. And also just really validating their experiences. The gentleman who, the officer who was in Iraq that I was talking about, I actually had to help him get hospitalized. he came into my office instead of I found him in the hospital today. I'll be dead tonight. And I couldn't get his commanding officer to take him. I couldn't get the ambulance to take him either.

Everyone was afraid. It was a really intense moment. And I actually said, all right, for this moment, we're just, you know, wearing uniform together and I'm your battle buddy. And I personally drove him to the hospital and called the attending, who said, meet me outside the elevator. rode the elevator up to the unit and he tended open the door and I walked him on the unit. It was the only way I could do it because we were on base and it was the only time of my life

I've done something like that and I don't regret it and I don't advise it being a practice. Right. Yeah. I think sometimes we do what's in the best interest of the patient. At the end of the day, I had this one person reach out to me on Instagram and they were like, I think my patient has acasthesia and this was like, you know, a therapist. who's listening to the acasthesia episode. And so there are patients like pacing around restless on high doses of antipsychotics. And I'm like, well, I think you should call the attending. And there was all this fear around calling the attending, you know,

because that's not normal protocol. Normal protocol is going to my boss, but my boss doesn't even, doesn't really know what acasthesia is. I said, sometimes you got to do what's in the best interest of the patient. You know, at the end of the day, like, we can't get too far away from doing what's in the best interest. of the patient. And sometimes you have to, you know, change the rules a little bit. It's not the normal thing for you to probably drive this person to the unit. You drove them to the unit. Is that right? Yeah, literally. It was the only way I spent it like an hour trying to convince people. He was

clear with me. This guy knew weapons very well. Yeah, yeah, it's one of those things. Yeah. I had this one, I had this one ex-cop who was undercover for, decades. And so he didn't look like a cop. He looked like a thug. And no one would see this guy without security. And I think the first couple times I had security outside my door, you know, but then I eventually saw him alone. But it just some people are really scary. They look, they just look, they just look scary. And I think that's part of working with this population is to realize like, just because they've been violent and war doesn't mean they're going to be violent. in your office, you know, unless they have a history of becoming unhinged with people who are

civilians and normal people or providers, you know, if they have a history of violence in war, they're probably not anymore at risk of being violent in your office than a normal person, I would assume. No, I never. I had the, yeah, I had the luxury of personal experience that kind help me understand what you were just saying. And I wasn't at all worried about him hurting me. I was 100% worried about what would happen if he left. Because I'm confident something bad would have happened. I don't, of course, can't actually forecast.

But yeah, these are folks who, you know, identity, like we're saying, you know, identity matters. And, you know, occasionally it's like, you know, my identity. Yes, I'm a psychiatrist. Yes, I'm a healthcare professional. If you're also a veteran, if you're also active duty at the time, you have all these different things that you represent to the person that you're caring for. And sometimes one of those identities steps forward more than the other. And I think if you can respect that and observe it and be transparent about it,

you can use it to help people. I just have to be careful. Yeah. Okay. I have a story for you. And I've never told my audience this story. This is one of the reasons why I went into psychiatry. So I'm a third-year medical student.

I'm going to change a couple of facts I always do to kind of like hide the patient's identity. You wouldn't be able to trace these stories back to any particular person. So I don't feel like I'm violating HIPAA or, you know. But it was this older guy who came in to the ER, and I'm seeing him. I was on internal medicine. He had like new onset diabetes or something like that. But I get talking to him. And I just, I had this weird feeling like, I'm going to have a,

I'm going to have a deeper conversation with this guy. You know, things were slow. I didn't have like six patients to go to after. So he was a, he was a Vietnam vet. And he was telling me he hadn't slept well since Vietnam, which is like 40 years or so. And so I asked him, like, questions about it. And he was pretty guarded.

And I said, you know, I think it's really hard to tell these stories. I think it's hard to, you know, tell the truth of what happened, which may be troubling you. And so he told me two stories that were moral injury stories. The first one, he was in a tunnel and there was someone up ahead who was an enemy combatant and he shot him. And then when he crawled to the guy, he realized it was a, like a 10-year-old. And that was like, definitely something that would repeatedly come out

as like guilt, shame, violation of, you know, his moral code. He was Catholic. And the second thing was, he was hungered down with two of his buddies. They were receiving heavy fire. And he injected his buddy with morphine. And the guy,

his buddy was shot. really, really bad. And his buddy was still in pain. And he knew if he injected his buddy with more morphine, he might kill his buddy. And so when he did, he blamed himself for the death of his buddy and blamed himself for not like going in front of the line and, you know, his buddy being there. And so he had survivor guilt. So he told me he had never told anyone this story before. and I think I think that was the honest truth he was pretty guarded about it initially

and he was Catholic and so he wanted to utilize his spiritual resources he ended up praying and I was there with him during that and so I checked on him every night after that every day for the next like five days he's in the hospital

and every time I would walk into the room he would just have this big smile on and he'd say, I slept through the night. And I almost like didn't believe it, you know, that like one event could change is like sleep, right? And so I wrote down his MRN and called him up about two months later just to check in on him. And he said, yeah, he's sleeping great. He had other problems, you know, going on like most people do, you know. Right. Oh, I'm having some conflict with my girlfriend, you know, but I'm sleeping so much better.

And I don't think about those things anymore, you know. And I've started reengaging as Catholic background. So when I was reading this paper, I was thinking, like, wow, that guy, it wasn't normal PTSD. It was definitely a moral injury. And just listening in the right way and helping him utilize his own sources of strength that he already had that he wasn't utilizing. for him I think it was like tapping into this idea of forgiveness that he could be forgiven for this or that he deeply didn't want this to happen and that he could be forgiven. I think that was helpful for him.

Right, that a human being could hear this story and not reject him. That was probably part of it, yeah. The powerful part is like I could, I stood with him with like, you know, kind of like no judgment that this stuff happened and some compassion for him and the amount of suffering and knowing that he wouldn't have wanted to kill but that was like what happened and it violated his his moral code i think he would have i think he wanted to you know do what was right and it just was a huge violation of what he felt like was right. Yeah, yeah.

That is a common experience, I think, for folks working with veterans. And as you're saying before, it's not confined to military. It's anybody on the front lines of emergency medical services or law enforcement health care providers. I'm sure, of course, educators, the list was long in some of these research where they found different categories of people where you can suspect some percentage of them. CPS was a big one. I had another IOP patient I worked very closely with, did some therapy with as well,

who felt like she would uncover abusive situations that kids were going through. and report it, but then they wouldn't do anything about it. It would, like, get stuck at the upper levels would stop it. And that was like a moral injury for her. Really, really troubling because she had a history of abuse. She was going into this field to help kids, and she was having an hard time helping kids get out of the situations that they were in, just these dire situations sometimes.

So yeah, it could be, you can imagine as you're listening to this, I'm sure your patient's stories are coming to your mind. I'm sure your own stories maybe are coming to your mind to places where it's like you were just, you felt stuck. How do I make this better, you know? How do I make this system better that's not ideal? Right. Yeah, a lot of what you're describing to, it's reminding me why I say all the time.

I don't do med management. Nobody does med management because I don't like that term because it implies that the patient is the pill. It implies that we're not producing suffering or facilitating some sort of transaction. Because for these kinds of cases, if you don't have enough time to sit in silence and really listen, they're going to look on the surface like other things that could possibly, where you could come to the conclusion that, oh, an SSRI is what's indicated here, which is not to say that none of these cases we're describing, you know,

include patients that would benefit from SSRIs, but to lose the context, you could possibly lose everything and unknowingly have an interaction with somebody where they feel invalidated when you completely missed the point, which is not to say, again, not to say that, you know, medicine is bad or wrong or whatever. It's just when you're talking about a cardiologist, nobody says, you know, oh, I have a cardiologist and then I have a medvedement cardiologist. You know, you have a cardiologist, they treat all things related to the heart. And as that relates to the rest of your body, you have psychiatrists, you know, we should be having enough time with individuals to make sure that that context is appreciated and understood.

And that's really hard when the patient has a therapist that you maybe don't know well or don't get a chance to really communicate with often unless you're doing the therapy yourself or you're simply having longer sessions such that it's sort of like at the very least supportive psychotherapy and motivational interviewing. To get the information you need to really help this person and establish that trust or even if they're getting CBT or somebody else. Yeah. Yeah.

So there were two other things you wanted to kind of hit on. And I think they kind of tie in to what we're talking about. One is identity is respected, right? So you talked about how if you're, talk about how the provider can't let their bias slip in or if they have too much bias, maybe it's not the right person to help. Talk about that a little bit. Sure. I think just like if you're somebody who works, for instance, with victims of sexual assault

and your go-to is to wonder what that person did to bring on being sexually assaulted or what sort of irresponsible behavior they were engaged with that maybe set them up for this, you probably shouldn't be working with victims of sexual assault in a similar way. if you're working with veterans, you're working with active duty service members, and your bias is to assume, but you never should have enlisted, you know, you never should have gotten a commission. Don't you understand the military industrial complexes, blah, blah, blah. Now, no judgment for people who want to confront governments or be critical of warfare

because I certainly am critical of governments and warfare. But if your way of approaching the world is such that that's part of your identity, and you're not able to step back and be curious and compassionate, both across the full spectrum of understanding what may have occurred, and very specifically for this individual, then you probably should look for someone else to help take care of them, because that's going to seep through. you know if if uh because i i have met with therapists who have said like well yeah you know i'm not

i don't really like working with the veteran population they said they knew what they were getting when they signed up and that's an awful thing to say yeah yeah i almost want to like yeah well i mean like yeah probably refer that to a colleague who has some compassion or just don't work for the va or you know yeah so it's like you have to because what you said is it's important for them to understand like to some degree what they were doing was meaningful and it has to I think that's why world war one and two is like a little bit easier than vietnam and some of the other more ambiguous wars it seemed very sort of black and white right the you know Nazis are bad and they continue to be bad anyone who's bad is called labeled a

Nazi, right? So it was very clear like you were a hero. And I think in some more of these ambiguous wars, it's like it's a little bit harder to have that narrative be so strong. Yes. Yeah. And we've, you know, we now have a very much a professional military, right? So it's not the situation, you know, like you're mentioning in the so-called Great War and, you know, US sat back and waited until it was, things were so bad, there was no choice. Or at least that was a person. That's in retrospect, that's I think, what most of us have come to, you know, that's, that's, that's the narrative that gets sold to us, whatever, you know, whatever, however you

interpret that. And things fast forward, the last 70 years have been more about prevention, police force, almost being a so-called world police at times is how some people will describe what NATO countries or the United States, you know, efforts that by the United States have been like where it is much more great. It's much more ambiguous and confusing. And you're expected to come home, you know. So I think, you know, folks who were marching across Europe during World War II

are like, we're either going to win or we're going to die. Those are the two, you know, those are the two options. Whereas in today's wars, it's like, we're going to win or we're going to die, or it's going to get really gray and muddy, and then most of us are going to come home. And most of them do come home, but they're coming home with these problems. And, you know, they're coming home with head injuries. They're coming home with PTSD. And they're coming home with moral injury, specifically, which is poorly defined.

And we're all still struggling to figure out what that means. what does that mean for society? And what does it mean when a person lands in your office with this thing that doesn't fit nicely in DSM-5? And there's not a pill for it. And the psychotherapies that are being developed and deployed to help treat it are in very, very early stages of being researched and appreciated. I think most therapy is going to work for most people.

I think if the practitioner understand. a little bit about moral injury, they'll probably be a more effective provider because they'll know the right questions to ask or why this might be difficult. Okay, there's one other thing you wanted to hit, which was that you think it's important for people to believe that they're going to get better and that they respond to that sort of thing. And I found this as well with patients. There's, there's, you know, since I run a program for people with medical problems and psychiatric problems, They come in often with this thought that this medical problem is going to keep me disabled for the rest of my life. And it's hard for them to break free of that sort of narrative.

And there's secondary gains that are known and unknown for that. The family sometimes has secondary gains. So it's, yeah, and tell me your thoughts on this. Yeah, yeah. I think the financial and political systems we have that are intended to support people who are suffering sometimes backfire for the patient. When a person's identity is shattered and it gets reformed as a sick individual and they find themselves thinking like, oh, well, you know, I'm getting compensated for being sick. this is now who I am. It's an easy identity to construct. And it does, at least in the short term, help people get by. It gives them something to bond with others around. It gives them something

to talk about. And then there's financial reward. And so cutting through all that can be really challenging. And I think when we're dealing with veterans who have symptoms of PTSD and a moral injury, it's really important to help them understand that you as the therapist are leaning in with with hope and optimism. That's your lens. My lens is, you know, I don't care who pays you what, you know. That's this. I don't care if the U.S. government gives you $100,000 a year for the rest of your life for whatever reason,

for just simply because you're a veteran if they want to or because you used to have PTSD. But I'm telling you, you can recover. and my job, I'm not going to rest until I think that we've done everything we can to make your life as fulfilling as possible. And you can see how horribly the system has treated people because there's a lot of folks who never come back when you say that. And the ones that do sometimes come back like, wow, you know, no one's really, no one's really said that to me before. and I just, I have a second wind, you know, and I want to hear more about what we can do because you gave me a few pointers, you know, I already started going to the gym, you know, I already made that phone call and I've reached out and I've got a, you know, a first intake psychotherapy

appointment in two weeks and, you know, and you just wonder how do we reach those folks you, that for whom that's off-putting. And there has to be a systemic approach because it's not something something the individual provider can do because they have to actually be in your office. Right. So there's powerful secondary gains. It's great that we have the ability to have some of those as well. It's great that we have a safety net for people who are really struggling. PTSD on some of these like psychiatrics things, it's like if in their mind they believe there is no exit, they're never going to get better, they're not going to be able to rejoined society, you know, it's like, it's like there's something that happens inside of their

mind where then they just don't move forward. You know, it's like that kind of like learned helplessness type of thing that happens. It's like, okay, there's no reason to work hard on this to overcome this. This is an insurmountable burden. I've seen it as well with people in like lawsuits. And for them to win this lawsuit, they have to be ill. And so they've been coached probably by a lawyer to report things to me or to be ill. Or somehow unconsciously, that's in their mind. It's hard to discern if it's like malingering. Malingering is when they're directly lying or if they're just believing this enough

because they know they need this for their family to survive. of, you know, they need this huge lawsuit, whatever it is. Interestingly, one service member, not like the military, but outside of the military, he was seeing me pretty faithfully for about two years. And then I was part of a deposition. And then he never saw me again. He got what he needed. And he moved on.

And in retrospect, I probably helped his court case. But I think also I, you know, I wasn't like, now, now I can look back and see how maybe he was looking for me to have these symptoms in his chart, you know, and it's unfortunate. But, you know, so people have secondary gains and it's like, how do we help them overcome that? It's really one of the harder things that we have to face because often they're entrenched in their secondary gains in their family as well. like the family is benefiting, the family is trying to keep them in this sick role and shame them back into sickness almost, right? Right, right. Yeah, and almost all the things that go into that put people at increased risk for adverse events,

right? So these are folks who are usually physically inactive, they're usually socially inactive. They usually have some form of addiction, nicotine, alcohol. all. And they're just, and they're, they're not deeply socially connected. So something happens, you know, where they need to lean in and ask, you know, ask people to lean in and see if support, there's not too many folks there for them. And so it's not, it's not just, you know, ethically, legally ambiguous. Like, these are folks who are suffering in ways that you can tell as a physician when you get to know the whole story.

But they're not coming in saying that stuff. You know, they're saying, oh, I have nightmares. I have depression. And it's always going to be here. I need to see you every six months so I can send a copy of this evaluation to the VA. So they can send it to my case manager. Those are the, you know, things that people say. And that's your opportunity to say, oh, okay.

What's going? So what's going on in your life? So what are you doing to treat these symptoms on how can I, how can I help? And it's extremely challenging to help the folks who made it clear that they don't want that. I know there's a lot of people who, I think the natural impulse is to be upset about that. But I think we need to be very compassionate for the fact that these are individuals who have been molded into this by others. And we need to be deeply curious about the origin of the suffering that would give themselves permission to let that happen and perpetuated. And then compassionate for ourselves when we have that feeling emerge.

Like, wow, you know, I feel contempt. Where's that coming from? What is going on in my own life that's helping, that's causing me to feel this contempt? Because this is just a human being across from me that's suffering. And I'm a, I'm here to deliver, you know, something that's going to make them better. And that sense of entitlement that I'm feeling right now is doing nothing to help me help them. Yeah.

Yeah, that's good. I think we have to look at ourselves and do our own work so that we can stay compassionate, definitely through and consistently, you know, both the voice of, like, hope for them, but also empathic to the distress of overcoming. and launching and venturing out and, you know, changing the equilibrium. And this is where I think, I think it's so important to look for congruent affect, you know, if someone is telling you the symptoms and there's like the congruency of the affect, you know, the internal and external don't match, right?

So the internal experience of their affect is like, they look pretty cheerful. They look pretty happy. But then they're describing something that's very different. It's like we want to look for what's congruent. And I want to spend my time in therapy there. And sometimes it's really hard to get there. So sometimes I use writing or even artwork to try to get someone into a congruent space. It's like what is talking congruent?

Is writing congruent? Is art congruent? Which is the most congruent? And then let's bridge from there to the other ones that are congruent. you know if if the the trauma that they're reporting is not congruent what is the congruent distress that they do have or maybe they feel they're congruently happy for some success so we can be enthusiastic and and connect with them with their successes and i think it's much more important to do that than to look for something that isn't there some sadness or some emotion that isn't there

and connect with them only in negative emotion. So we need to connect both with the positive and the congruent negative emotion. And I think that's the daily work of the therapy that then moves the person forward. Right, right. Everything is, there are things other than lingering in PTSD. Somewhere in between is like most of humanity.

Right. Oh, the other thing I was thinking about is like people with like chronic back pain like sometimes exercise actually makes it better fibromyalgia exercise actually helps it moderation moderate exercise not too hard and um so even that kind of stuff it's like if you're stronger you're going to be less likely to have pain i've had a number of friends who have chronic back pain real have had you know bulging discs or real issues and then they start squatting deadlifting their pain actually decreases you know thoughtfully doing it right with the correct technique and everything and a coach so so even like

like sometimes even the physical stuff it's like can be overcome so i i i it's like when someone comes in and they're on the amphetamines the opiates the benzos it's like how do i motivate this person to get off those things and and and often marijuana as well or some other intoxicating substances and then get on this path to like recovery so that they can thrive. It's tough. It's really tough, especially if that's not what they want for themselves. Right. Or at least superficially want for themselves.

I think deeply they want that on the deepest level they want that. Yeah. Yeah. And to bring us back, you know, a little bit with moral injury that it's, you're really trying to understand what is this person's, what was their identity for these events or this singular event? And what is it now? What does that mean?

And how is all of that correlate with the things we know, make a person healthy and allow them to progress with purpose and meaning? And I think, you know, I think it becomes really important to, to spend enough time with our patients to figure out how to create space so that they can actually divulge what those things are. You know, it's super easy to get a PHQ9 and ask all the questions to figure out someone has major oppressive disorder, generalized anxiety disorder, those things we can accomplish pretty quickly, pretty, and it's fairly simple.

But to create a relationship and a space, emotional space, for a person to divulge to you, this is what gives my life purpose and meaning. And maybe right now the things that are giving their life purpose and meaning they know are counter to who they were before and there's an incongruence and they need to reconcile that. And they were desperate for someone to give them permission to do it and to go on a journey with them to sit in that uncomfortable space and be very uncomfortable with these stories

and let that happen. just let that discomfort exist between inside you and between both of you and in them and not be afraid of it and I think I think that's that's where this work is really done that's good that's I think that'll that'll be a good ending thank you so much for coming on and thank you for for sharing your journey here and your service and and your passion for this population and for for moral injury and how we might better help people through it. So I appreciate that. Well, thanks for having me on and thanks for doing this podcast.

It's become a part of my life and it makes my life better. And so it does. It's hard to think that that's the case, but okay, I'll receive that. I'll keep telling you until you believe it. So you can internalize it. Your podcast makes my life better in many different ways. And I'm very appreciative. And I'm flattered that you have me on.

Thank you so much.