Eric: Welcome to the GeriPal Podcast. This is Eric Widera.
Alex: This is Alex Smith.
Eric: And, Alex, who do we have with us today?
Alex: Well, joining us again as co-host is Anne Kelly, social worker at the San Francisco VA. Welcome back to the GeriPal Podcast, Anne.
Anne: Hi, guys. Nice to see everybody.
Eric: Otherwise known as the voice of GeriPal. There were a couple of weeks where Anne was not introducing the GeriPal Podcast at the start, and we got hate mail.
Alex: Yeah, I apologies for that intro, everybody. [laughter]
Anne: My fan base was very upset. But I’m back, everybody.
Alex: Much better with Anne doing it.
Eric: You have a very vocal fan base.
Alex: We also have Shira Maguen who is a professor at UCSF in the School of Medicine, and is also Mental Health Director of the Post-9/11 Integrated Care Clinic at the San Francisco VA. Welcome to the GeriPal Podcast, Shira.
Shira: Thanks so much for having me.
Eric: We’re going to be talking today about moral injury, including moral injury with COVID-19 in veterans, and a lot of different issues. But before we jump into that, Shira, do you have a song request for Alex?
Shira: I am a big Beatles fan, so I would love to hear something like I Want to Hold Your Hand.
Shira: Impressive. Thank you.
Eric: Nicely done, Alex. Shira, let’s talk about moral injury. First of all, what the heck is moral injury?
Shira: So I’m going to offer a definition and see if it feels like it’s a good one for people to work off of. So the definition that we most typically use for moral injury is a mouthful, but I’ll walk us through it. So it’s perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.
Shira: So the idea here is that you actually cross a line. So moral injury requires actually an act of transgression that contradicts either personal or shared expectations about the rules or the codes of conduct.
Shira: Really the idea behind moral injury is that you are crossing some kind of line and, as a result, you’re experiencing distress. Most typically, some of the hallmark symptoms of moral injury include guilt or shame, anxiety, distress, and really withdrawal. People suffer quite a bit because they experience, again, what they perceive as a crossing of a line of their morals and values.
Eric: Yeah. How does it differ from other DSM–5-like conditions like PTSD in reactions to stress and fear?
Shira: Great question. So I think when we think of moral injury, we don’t think of a diagnosis, but we think really of moral injury is more of a dimensional issue. So it’s a reaction that people sometimes have that is not something that you can look in the DSM and diagnose, but that it really is about how you perceive yourself, how you perceive your spirituality, and how you’re really integrating what you did or what you witnessed in terms of your own morals or values.
Shira: And so, with PTSD, we really think of you have to be exposed to some kind of trauma as the basis of PTSD. Similarly, with moral injury, you’re exposed to what we call a potentially morally injurious event. So that can be many things in the context of war. It can be, as we talked about before, perpetrating taking another life. It can also be witnessing something horrific, but it’s not necessarily a trauma. In moral injury, you may have done something, whereas, more typically, in PTSD, you’re experiencing some kind of life threat.
Shira: So the type of the trauma is really, really different in both of those conditions, but what follows with PTSD is very much a list of symptoms that you have to meet in order to get a diagnosis. So we know that with PTSD, people may have re-experiencing symptoms, so that comes in the form of intrusive thoughts about the trauma. It comes in the form of nightmares. People might withdraw. They might avoid reminders of the trauma and also experience pretty extreme vigilance, so being on guard, being easily startled. That really is the package of symptoms that makes up PTSD and causes people functional impairment.
Shira: With moral injury, again, what people are struggling with most is the shame or the guilty because of what they did or didn’t do during the morally injurious event. It’s also the ways in which they react to that event can be very different. And so, they can withdraw.
Shira: What we often see with moral injury is that people feel like they don’t deserve to be happy in their life or they really have a lot of negative feelings about themselves because of what happened. They go on to oftentimes engage in self-sabotaging behavior. So drinking, overeating, potentially using drugs, and, in the worst-case scenario, feeling suicidal or taking their own life in the most extreme case.
Shira: So I think that we see a lot of self-harming and self-sabotaging behavior because you feel like you have done something bad, you have done something wrong. And so, another big piece of moral injury is oftentimes self-forgiveness and struggling with how do I forgive myself.
Anne: When we think about someone who’s suffering from symptoms of moral injury like you described, what might be other signs … Like how might that be affecting their relationships or the relationships with other people in their life?
Shira: Great question. And so, I think a lot of times that there’s a lot of functioning difficulties because of these symptoms that I’m describing with moral injury. So you imagine like if you’re carrying around a lot of guilt and shame and don’t feel very good about yourself, that’s going to impact your ability to be in a relationship with other people, certainly family members, certainly loved ones.
Shira: And so, a lot of times part of that self-sabotaging behavior is I feel like I don’t deserve to be happy because of what I did or what I saw in war, let’s say. And so, then you feel like if you don’t deserve to be happy, you withdraw from your relationship. You might not talk to your partner about what happened, and that might cause ongoing problems with relationships. Of course, if people are drinking or using drugs, that also really complicates being able to connect with others.
Shira: I will also say that with some of the veterans that I work with, many of the veterans that I work with in particular experienced killing in the context of war and really have a lot of shame and regret about that. And so, these are the ones who experience moral injury.
Shira: And so, I think that that also really manifests in terms of the relationships, and particularly if they killed or harmed young children and then they’re coming back to lives in which they too have young children. Those children are a trigger for that in terms of what happened during the context of war. So I think it becomes very complicated with relationships. And not only relationships, but also within a work context as well, too.
Eric: Shira, can I take a step back? How did you get interested in moral injury as one of your research and clinical expertise areas?
Shira: Great question.
Shira: It’s been a journey. But, yeah, I think that when I first became interested … So I’ll take a few steps back to say that basically in 2001, in September of 2001, I started working at the Boston VA. Then 11 days later, 9/11 happened. And so, I was working with veterans. As the years went by, the veterans went to war and were coming back from war, and I was, at the time, working at the National Center for PTSD.
Shira: And so, we were very much emerged in thinking about PTSD and thinking about how to help veterans who are coming back with PTSD and helping them adjust. We were doing evidence-based therapies for PTSD. So prolonged exposure, cognitive processing therapy.
Shira: What we were finding is that even after we were doing the top of the line treatments, a group of people were still really struggling. These were veterans that I was working with directly. So at the time, I was working with one veteran who was a medic, who was really struggling with the fact that not only was he not able to save people because he didn’t have the time or all of the materials he needed, but in addition to that, he killed in the context of war. And so, he had a very difficult time integrating his role as a medic and what happened in war, both feeling like he killed people in war and also feeling like he wasn’t able to save people.
Shira: And so, what we were seeing were just these very complex situations that didn’t really fit into our conceptualizations of PTSD. And so, I think experiences like that really got me to thinking in much greater depth. For me, a lot of those experiences were particularly veterans who had killed in war.
Shira: So at the same time, there was a New Yorker article that actually came out really the same year as I was starting to think about this that was really criticizing the VA for not dealing with the issue of killing more directly and helping people. And so, the stars were lining up in terms of just both my thinking and also in terms of some of the media pieces that were coming out at the time. I felt like I really wanted to understand this in much greater depth.
Shira: At the time, we weren’t even calling it moral injury. And so, even though I think people have been working with them, thinking about moral injury for many, many years, I mean since the time of the great tragedies really, but I think that it really, from a psychological and from a mental health perspective, it wasn’t yet on the map in the same way.
Shira: And so, there really wasn’t a language for it yet, it felt like. And so, when I looked into what was out there, about the impact of killing in war, I found very, very little at the time. And so, I really understood that what we needed to do was if we wanted to understand the impact of killing and moral injury more broadly, what we really need to do is start from the ground up.
Shira: So that’s when we started having focus groups with veterans to understand this to a greater extent. We started looking from the research perspective as well at how people who had killed in war were actually faring long term. So that’s where my interest really grew out of my own clinical experience and from the veterans that I was seeing. It was their voices that really amplified for us that we needed to be thinking about this in a different way and listening to those voices and hearing that that was something that we needed to address.
Alex: Can I ask a clarifying question?
Alex: I mean you mentioned the killing of children, which is just horrific to think about and clearly would violate most people’s moral code or moral sense of morality. Does it have to be something as egregious as killing of children or unarmed civilians, or can it be killing of an enemy combatant who is shooting at you?
Alex: I could see arguments for both. I could see, on the one case, killing of children, this is something that is not a part of the ethics of war. Killing somebody who’s shooting at you may be accepted in ethics of war. On the other hand, it’s killing another human being, which in and of itself is a distressing act. So I wonder if there’s a distinction there.
Shira: Yeah. No, that’s absolutely right. I think for what we have learned from working with many different veterans is that each case is its own unique story. And so, there are absolutely people … It’s the full gamut. For many people, they’re incredibly distressed by killing an enemy combatant, even if that enemy combatant, it was very clearly a situation where either it was going to be them or that person in the context of war.
Shira: I think even for many veterans, even when they’ve had the training and they’ve been prepared for what’s going to happen, in that moment where you have to pull the trigger, we’ve definitely heard over and over again nothing can really prepare you from that moment, even if it’s under circumstances where it’s an enemy combatant.
Shira: I’ll also mention that for many people, they kill … Like in Vietnam, there were bombs dropped and people who didn’t get to actually see what had happened, but it can still haunt them just the same. And so, it’s not necessarily a particular type of person, it’s not necessarily from a particular distance. People can suffer tremendously because of the thought of what they have done and just imagining the circumstances of what had happened.
Eric: I guess one question too, which seems to come up every time we do a co-ed podcast with somebody who’s been a healthcare provider, who’s been in like a surge situation … For example, we just did one on COVID-19 hospitals and talking with somebody who was in New York during the big surge and feeling like she as a nurse could not provide the care that she felt was the right care for people, just because of constraints, resource limitations, and the distress that comes with that. Does it have to be like a war or can it be situations like what we’re seeing with COVID-19 over the last year?
Shira: Great question. So it can definitely be a situation like we’ve been seeing with COVID-19. I think that the majority of work with moral injury, just from the perspective of the research, has really been mostly with veterans in war. But we absolutely have known for a long time now that healthcare workers too can be … Moral injury applies to healthcare workers, especially in the context of pandemics.
Shira: We’ve been doing a lot of more thinking recently and understanding that we need to expand both our clinical understanding, our research understanding of how this impacts healthcare providers, and not only healthcare providers but first responders across the board in a pandemic, in a healthcare situation, where people don’t have adequate resources or have to make really difficult decision that they don’t always feel prepared for. For example, like within the pandemic.
Shira: And so, again, I think that there’s a lot of examples of potentially morally injurious situations that happen in healthcare, but oftentimes it’s really about did the person feel like they did something that went against their values? Did they witness something that went against their values? Or did they feel like, in some cases, they weren’t getting the support both in terms of like the supplies that they needed or the mental or physical support in terms of leadership that they needed in order to do their job?
Shira: So I think it’s very relevant to the pandemic and I think a lot of what I’ve been seeing, both in the research literature as well as in the media, really speaks to that this resonates with healthcare providers and that, unfortunately, we’ve also been, in rare cases, seeing some suicides in healthcare providers that really feel caught in the struggle of how do I care for all these people? How do I do my job in an impossible situation sometimes when there’s so many people who are dying around me, and I can’t do what I typically do in a normal situation?
Alex: There’s also a sense of betrayal, that the healthcare system isn’t supporting the healthcare workers in the way that it should with PPE, for example, or the tension to the distress that healthcare providers are going through in caring for people like this. That may not be the sine qua non of moral injury, but it certainly is a contextual factor that is probably true as well among soldiers in the war.
Shira: Yeah. Betrayal is actually an important piece. I think that the systemic issues that you’re talking about right there can be physical support with supplies, et cetera, and then there can also be the psychological or the emotional support, and how do we care for people systemically who we know are suffering in ways while they’re making very difficult decisions in caring for patients, but also then risking their own families, especially in the early days of the pandemic where there weren’t vaccinations and they were coming home to families of people at risk and children.
Shira: And so, that also factors into moral injury, too. It’s not only what happens at work, but it’s the decisions that you’re making in your day-to-day lives and every day that you come into work. You’re risking, in some cases, your family’s well-being, too. So that all absolutely factors into the picture, too.
Eric: Yeah. I mean it just reminds me, again, going back to that COVID-19 in hospitals podcast, like every day, every hour, especially during the surges, people were making decisions and were making really hard ethical and moral decisions about who gets what, who gets my time. I think we were talking a lot about there were plenty of ventilators, there just weren’t enough people for those ventilators.
Shira: That’s absolutely right. I think that that’s, again, very similar to what we know happens in war. So in a battlefield, there’s a war that we were fighting with this pandemic to try and save people. I think people did have to make very difficult decisions without always having all the information, and I think that there are a lot of parallels there.
Eric: Yeah. So what we do as healthcare providers? So it sounds like this is very common in veterans and potentially other populations. Should I be asking or assessing, even how would I assess for it if I wanted to assess for moral injury? Then maybe we can argue about am I just opening a Pandora’s box that I cannot close? What do I do with that information?
Eric: Let’s talk about the first part first. Go ahead, Anne.
Anne: Can I add, I’d be curious to hear, Shira, if, in your experience, you find that people who are suffering from moral injury actually, do they actively seek help for it?
Shira: Yeah. These are all good questions. So how do you assess for it? How do you treat it? Are people even going to come in for health? So what’s interesting … Maybe I’ll start there, because in order to assess them, they have to actually come in the front door.
Shira: What we have found is that people are much more open about experiences of PTSD than sometimes they are about experiences of moral injury. So even in some of our treatments, we’ll hear about PTSD experiences or traumas, and then only much later in the relationship with the veteran hear about moral injury events or moral injury.
Shira: And so, I think, because of the way that our culture has set up being able to talk about and process experiences of war, there’s a lot of stigma and a lot of shame in even raising those issues. We’ve heard many times over, like, “Oh, I didn’t realize it was okay to talk about those experiences. I thought that that’s something like a secret that I should keep till the grave.” And so, there’s also the sense that it’s just not okay to bring it up or that somehow like I did this and I have to just never bring this up among anyone, not my healthcare provider, not my family.
Shira: And so, I think a big part of even beginning to talk about this is making it okay and naming it, being able to name. Moral injury is something that happens, and I think it’s true of veterans and I also think it’s true of healthcare workers because there’s stigma in both of those groups about bringing the fact that there might be any guilt or shame related to what you did in war or what you’re experiencing in healthcare.
Shira: And so, I think that that conversation is a really important one, that people may not even feel okay to open up about it. So obviously that makes assessment a little bit harder.
Shira: But I think what we have found that people do eventually when given the space and given the language. And so, a lot of times when veterans haven’t heard about moral injury and we define it for them and bring it up, it really resonates and makes a lot of sense.
Shira: It feels like even when we use words like killing, we’ve gotten a lot of feedback that that feels validating because we’re naming what happened as opposed to coming up with some acronym that brushes it under the table or doesn’t name what’s really going on for people or their experience. And so, I think that that’s an important first step, is just creating the environment in which people can talk about it.
Shira: In terms of assessment, I think that there’s so many different ways in which moral injury can manifest, but I think even beginning to ask about, again, in the context of other experiences, like, in war, did you witness the death of another person? Did you experience injury yourself? Did you experience someone else being killed? Did you yourself kill another person?
Shira: So, again, we’re asking about these experiences regularly in the context of normalizing these questions. I think, still, people will feel stigmatized, but I think the more we can have these conversations with people … And usually they happen, I would say, most often in a mental health relationship or it’s an ongoing relationship, and it can feel safer for people to talk about these things. But again it varies on the environment.
Shira: And so, if we find that people have the exposures, it’s also good to inquire about … And there are particular moral injury measures out there that people can use in their clinical practice for sure, but I typically tend to ask about, “Is there anything from war that you feel guilty about or that you feel ashamed about?”
Shira: I also ask questions about whether people’s spirituality has changed, and I’m looking for are there any, what we talked about, self-sabotaging behaviors? Is there drinking happening, overeating, using drugs? Also, when we look at spirituality, have they let go of their spiritual side? Do they feel like they’re writing that off or they don’t believe in that anymore? So I think those conversations are also very important to have.
Shira: I think the point that is really important, it’s a constellation of symptoms that I often ask about, and that guilt and shame are often some of the hallmark symptoms from my perspective.
Anne: From what you’re describing also around the ways it can affect people functionally and interpersonally and spiritually, I could imagine that there’s a lot of different types of healthcare professionals who might be able to engage people in that assessment in different types of context. Then-
Shira: Very much so, yes. I think what I really appreciate about working in the space of moral injury is that we realized very early on, first of all, that this was really being looked at from many different perspectives. So we’re talking today about the mental health perspective, but philosophers have thought about this for a long time and write about this as well. Then the whole spiritual sector, like this has been a conversation among chaplains and among spiritual leaders for a long time.
Shira: And so, we have conversations in mental health, in spirituality among philosophers, among ethicists. This is a big topic of conversation. So all of those groups are thinking about moral injury, and I think that is really enriching in terms of what we know and how we’re thinking about it.
Shira: The parallel to that is when we’re treating moral injury, there’s a lot of different groups we can lean on. So there’s certainly the mental health professionals, so social workers, psychologists, psychiatrists, et cetera, that all can help with this, and yet that’s never enough.
Shira: So we know that healing necessarily has to happen in a much wider context. And so, spiritual communities are incredibly important to bring into the conversation. We’ve had lots of crosstalk with chaplains. Oftentimes when people are struggling with these issues, they want to talk to their chaplains. They want to understand, like, “How can I self-forgive not only from a mental health perspective, but also from a spiritual perspective?” That’s why it’s multidimensional.
Shira: Also their communities. So they want to be able to go into their communities and feel supported and feel like they can participate … Again, going back to that functional piece, Anne, that you were bringing up, this is where we look … We know that people are improving when their functioning improves. And so, that’s the barometer for us.
Shira: And so, if they were isolating before and withdrawing before and then we see that they’re going into their communities where they’ve been isolating from and they’re engaging in church or they’re engaging in sports groups or they’re engaging in those things that they’ve withdrawn from, then we know that the healing is really starting.
Eric: What are some examples of potential treatments? Because I’m guessing it’s not to make whatever bad thing that they did, to normalize that. How do you address this?
Shira: Yeah. I think that that’s a really critical point. And so, it feels, for veterans and anyone else who’s struggling with moral injury, inauthentic for us to try to explain away what happened. So that’s very much invalidating.
Shira: And so, I think part of being able to treat moral injuries is acknowledging that people had to cross the line and really balancing working with acceptance, acceptance and change. So there can be parts of what they did that they’re not considering to see really the full picture or expanding the lens out and understanding that they were in a very difficult situation. And it’s also very important to balance that with economic acknowledging the harm that was done, acknowledging the pain that was caused. Only through being able to really do that can people heal.
Shira: And so, I think that that’s a really critical component of being able to heal. People have to be able to talk about the wrongs that they feel that they have done in that context. I think that there are now more and more treatments that are emerging that people are testing for moral injury. And so, there are mental health treatments, but then there are also groups out in the community and there’s also some treatments that are being tested now that involve bringing in the community for certain rituals around healing.
Shira: And so, I think that, again, when we think about healing, there’s the individual-level healing and then there’s the group collective healing that needs to happen with moral injury too, and both of those are very important.
Eric: Yeah. We do a fair amount of teaching around ethics with our trainees, and we hear stories about moral distress that they have around particular cases. Sometimes just talking about like the ethical norms in medicine as opposed to their moral injury and their viewpoint, it sometimes helps in that they see things differently, that the ethics of it may be different than their own prior moral beliefs. Does that play a role here?
Shira: Yeah. I think that one of my favorite visits was actually to the Naval Academy, and they do part of their curriculum is ethics training. I think it’s an incredible piece of education to be able to give to veterans, to healthcare professionals, because it allows people to have a language to think through some of these very difficult decisions that might otherwise, like you’re saying, be simplified.
Shira: And so, when you start talking about ethics, you start understanding how multilayered and complex the situation is and really be able to see it from different perspectives, as opposed to really honing in on one perspective of I crossed this line, I did something wrong. You can really see the full flavor of what happened and really have different language to talk and think about it. And really realize that part of the reason that you’re struggling is because there is this moral compass and there is this very strong foundation for a lot of people, and it gives them the ability to really step back and have the language for that conversation.
Shira: So I couldn’t agree more that that’s just so important for many different professionals as they’re engaging in … Again, what you were going back to originally was these difficult decisions and very complicated decisions that have to be made very quickly sometimes that are about life and death.
Anne: Shira, as I’m listening to you, I’m thinking about experiences that I’ve had, and I’m thinking about a gentleman in particular. I’m taking care of people who are seriously ill and/or maybe approaching the end of their life, and we may not have many months or years to work on healing, working toward healing this part of them.
Anne: I can think of a gentleman once who we were seeing in the hospital, when folks were trying to optimize his symptom management plan, the veteran whispered to a doctor, “You don’t have to do that for me. I’m not a good person. I’ve done bad things.”
Anne: I think the folks in the room who heard that gentleman, their instinct, of course, is to want to offer reassurance and say, “Of course you deserve these things,” and, “Of course we want to do those things for you.” But I think he’s probably talking about something much deeper than what we were seeing there in that moment.
Anne: I guess I’m just wondering, when you think about some of the team members listening who might be taking care of people who are very sick, who might be expressing things like that to them, what might be some things that we can keep in mind in our care for those folks?
Shira: Yeah. Thank you, Anne. Such a poignant example. I think one that comes up not infrequently, certainly like in … And I think particularly poignant at the end of someone’s life. And so, as I mentioned before, a lot of times people are taking this to the grave, or it’s really coming out in the last phase of their life, because they haven’t felt like they had the space to talk about it before or felt too much stigma about that.
Shira: And so, from my perspective, I think that what can both be scary and yet create so much healing is just making the space for people to asking questions, creating space for people to talk about this. Oftentimes they’ve just kept inside for so long that they don’t recognize all the nuance.
Shira: So like for this man, I would want to hear from him why he felt like he wasn’t a good person. Even if he couldn’t tell me the details, to just really create the space where he had the ability to maybe talk about something that he’s never been able to talk about before.
Shira: And so, he’s already thinking about it. So you’re not going to be creating any more distress by just giving him the time and the space. This is something that he’s clearly worrying about and carrying and is coming out in the end of his life because he’s been carrying it for so long.
Shira: And so, I think that, in some ways, just, again, creating the space, and not trying to fix anything, not trying to get rid of the symptoms, but just acknowledging that this is something that he’s been carrying that is causing him distress right now, and not trying to fix it.
Eric: I can imagine any statement that you have to try to fix it for something that they’ve been holding on to for potentially decades and decades is probably just going to make it worse.
Shira: Right. You’re not going to be able to say the perfect thing. And yet ignoring it also sends a message. I think in some ways, we’re like, “Oh, that’s heavy. Let’s not open that up right now.” In fact, maybe it’s just giving him the space to talk about it in whatever way he needs to.
Eric: And sit with that suffering.
Shira: Sit with the suffering. Also, I think with this topic, what we don’t say speaks just as loudly as what we do say. And so, if we’re ignoring that, that’s also sending a message.
Eric: Well, Shira, if there is one thing you would like providers to do, you had a magic wand, what one thing do you want them to do around moral injury?
Shira: Great question. I think just using the language and being able to have some of those conversations, even if it feels scary at first, especially if a patient is bringing it to you, gently making the space to explore that further.
Eric: If I wanted to do a quick assessment, just even asking like, “Do you have any shame, anger, or guilt over what you’ve done in X?” so during COVID or during your time in Vietnam, does that sound like a good quick assessment?
Shira: I think that’s a great way to start the conversation, yeah. Again, there’s so many things we can ask, and a lot of times these conversations will get started because someone is bringing … Like just Anne was sharing, someone brings something to you and something resonates, like I wonder if that’s what’s going on here. I wonder if that’s moral injury.
Shira: So it’s those moments and then using your clinical skills to know what to ask. So it can be an opening question, Eric, like you were saying, or it can be based on something that the veteran, or even a lot of times, honestly, it’s their partners that are coming to us and saying, like, “I don’t know what’s going on here. I have some questions about it. I need help.”
Eric: Well, Shira, I want to thank you very much for joining us on this podcast. But before we end, I think we have a little bit more of The Beatles. Is that right, Alex?
Alex: A little bit more Beatles.
Eric: Shira, a very big thank you for joining us. Same thing, Anne. It was great to have you on.
Shira: So great to be on with you guys. Really great questions and discussion. Thanks for having me on.
Eric: As always, thank you, Archstone Foundation, and to all of our listeners for your continued support. If you have a moment, if you’d like to sign up for our weekly newsletter, go to our geripal.org website and put in your name and email address in our email submission form. Good night, everybody.