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Unraveling Moral Injury: A Special Episode for World Mental Health Day · Moral Injury Support Network Podcast

• 0:00
  Speaker 1: Hello everyone and welcome to today's episode.
• 0:03
  Speaker 1: I'm your host, monta Tere, and I'm currently interning with Missions.
• 0:07
  Speaker 1: I'm very excited to be part of this special edition that we're having for World Mental Health Day.
• 0:13
  Speaker 1: World Mental Health Day is observed on October 10th each year and is a global initiative at raising awareness about mental health issues and promoting mental health well-being for all, and I think it was very important for us to have a segment on this day in hopes to continue reducing the stigma and address any challenges associated with mental health.
• 0:38
  Speaker 1: So today encourages open conversations, education and support fostering a culture that prioritizes mental health and support positive change.
• 0:49
  Speaker 1: This is why we're happy to have with us today Dr Amanda Yac, who is a doctor of psychology in Asheville, north Carolina.
• 0:57
  Speaker 1: Dr Yac is affiliated with the Asheville VA Medical Center and Veterans Health, and her clinical passion includes working with trauma and moral injury.
• 1:08
  Speaker 1: I'm also joined by the Moral Injuries Support Network for Service Women's President and CEO, dr Daniel Roberts, and his senior exec officer.
• 1:20
  Speaker 2: Jamie P.
• 1:22
  Speaker 1: All right, how is everything doing today?
• 1:25
  Speaker 2: Good Good, Dr Yac.
• 1:29
  Speaker 2: We just want to say thanks again for joining us today.
• 1:31
  Speaker 2: It's a special treat.
• 1:33
  Speaker 1: My pleasure, my pleasure, we're the conversation yes, All right, so would you mind if we begin with my first question?
• 1:42
  Speaker 1: All right, so on our last episode we did touch on moral injury, but I feel like we didn't really touch as well.
• 1:50
  Speaker 1: So what is moral injury, and how does it differ from any other psychological conditions, like?
• 2:04
  Speaker 3: Yeah, I, when I think of moral injury, I think of it as a shape shifter, right, so we can look differently to different people.
• 2:13
  Speaker 3: And it's important, I think, to highlight that moral injury is not not to pathologize it.
• 2:20
  Speaker 3: It is a normal response to profound suffering and it spreads across bio, psychosocial, spiritual realms, right, when people are in positions or situations that transgress or go against the expectations they have or the beliefs they hold very, very, very deeply.
• 2:43
  Speaker 3: So you know, shay, kind of just.
• 2:46
  Speaker 3: Jonathan Shay describes it very simply as a violation of what's right, and the cool part about that is that it has a subjective component, right, like what's right to you and what's right to me, versus objective standards of moral behavior.
• 2:59
  Speaker 3: They can differ, and so that's the cool part about it is that it's very, it's very subjective in some ways.
• 3:07
  Speaker 3: With these core elements, what it feels like often in people who carry moral injury and who who are injured in this way is this erosion to somebody's sense of humanity and goodness, like their worthiness as a person, because of what they have done or not done, right Acts of commission or omission, what they have witnessed or experiencing betrayals, erodes their sense of worthiness, and I feel like that is this fundamental string, that I see moral injury through the lens of grief and loss and through the lens of worthiness.
• 3:50
  Speaker 3: I also think it's important to just note briefly that there is a spectrum here, right.
• 3:55
  Speaker 3: So moral distress maybe on one side that like we encounter all the time, and then moral injury as the kind of extrapolated version of that At the end of the spectrum, where the moral injury piece is identity altering, right, it has enduring impacts on people's lives and I think just it's nice to kind of start that out, this conversation that we're talking about like that type of heaviness here.
• 4:27
  Speaker 3: So, differences between PTSD and other things like guilt you know, guilt, I think, is a core component of moral injury as a shame, as is grief and loss, feelings of unworthiness, sadness, loss of trust, loss of faith, spiritual distress, loss of honor are kind of the heavy hitters, I think, there.
• 4:51
  Speaker 3: And then you know, when you think of PTSD you can think of it as very nervous, system based, right, like you're in the red hyper arousal head on a swivel, safety related, and there's a lot of overlap between the two, of course.
• 5:09
  Speaker 3: But there are situations that would be morally injurious where it wouldn't meet a criterion for PTSD, right, or there may not be that full like nervous system arousal component to it, and so I would say that that is one kind of big difference is loss of safety in PTSD and then on the other side loss of trust and loss of faith on the moral injury side.
• 5:38
  Speaker 4: So that's a very comprehensive answer.
• 5:39
  Speaker 4: I really appreciate that because I think one of the key things that we find, I think varies when you think about injury.
• 5:50
  Speaker 4: You think about physiological things a lot, but moral injury, the loss of self or self-esteem or value or worth, is a really key one and that's a really hard one to repair, I think.
• 6:08
  Speaker 3: Once you get a sense that I've.
• 6:13
  Speaker 4: If you perpetrated something, it could be something I've done, but it's something.
• 6:17
  Speaker 4: But someone does something to you Like now I'm trashed, I'm not worthy of anything.
• 6:24
  Speaker 4: Good, that's really hard to repair, right?
• 6:26
  Speaker 4: So yeah, and you know, dave.
• 6:32
  Speaker 3: Grossman.
• 6:33
  Speaker 3: He has this idea of like the like, this kind of triad of predator, prey, witness, and it's really interesting, particularly for combat veterans, because most traumas right that we encounter in the civilian world we're in one, maybe two of those roles, but when you're downrange or you're in theater, depending on your job, you know your predator, prey and witness and I think that the triad of those roles can add some complexity to how we see ourselves generally.
• 7:09
  Speaker 3: But a lot of our combat veterans, because of that, have perpetrator-based identities as well as betrayal, and so I think it just imbues it with a lot more color when we're trying to work with it.
• 7:24
  Speaker 1: And you said that there was some overlapping.
• 7:26
  Speaker 1: So is it a little like it's hard to distinguish between someone experiencing symptoms of PTSD and one that's dealing with more injury?
• 7:37
  Speaker 3: Yeah.
• 7:37
  Speaker 3: So I think you know the overlapping piece can have things like depression, anxiety, anger, insomnia, intrusive thoughts or ruminative thoughts, emotional numbing, self-handicapping behaviors, being isolated, right, like there's a lot of overlap in the middle of that venn diagram, but I think, in terms of the feeling, right, it can be hard to parse out, but when people are cloaked in shame, I just feel like you can feel it, you can just feel it Like there's something about it.
• 8:13
  Speaker 3: So all I would say is just listen, right, like, does it sound like it's fear-based, does it sound like it's a threat to safety and arousal, or is there something in here that feels like it's been lost?
• 8:27
  Speaker 3: Because if you ask people about loss, they'll oftentimes tell you about more injury.
• 8:33
  Speaker 3: Like, if you say, what did you lose in Vietnam, a lot of people will talk about their innocence and a lot of people will talk about their trust, right, in the government and the people they came back to, in the civilians that they were working with, you know, et cetera, et cetera.
• 8:53
  Speaker 3: And so, asking people about the things that they've been through that compromise their own sense of what's right, they'll talk about moral injury, right.
• 9:03
  Speaker 3: So, asking about the possible moral injury events, the PMIEs, what is it involved?
• 9:12
  Speaker 3: How has it impacted the way that somebody sees their life and sees themselves?
• 9:18
  Speaker 3: And you know, some of those core components would, I think, be pretty heavy hitters there.
• 9:23
  Speaker 3: Right, that guilt, that shame, a sense of brokenness or spiritual distress or existential distress are going to be pretty core to moral injury.
• 9:33
  Speaker 3: But I yeah, so it can definitely be hard to parse out, but if you just ask people and you listen, I feel like shame is very, very loud.
• 9:48
  Speaker 1: And what are some challenges that you see like in treating moral injury than unique compared to treating PTSD?
• 9:57
  Speaker 3: Oh Lordy, I got a lot on this one.
• 9:58
  Speaker 3: I got a lot here, okay.
• 10:01
  Speaker 3: So the first thing that comes to my mind is just how broad moral injury is right.
• 10:07
  Speaker 3: So it's not just I'm a psychologist right, but it's not just a mental health realm right, it is political and spiritual and religious and philosophical and psychological, like it's everything, it's all encompassing.
• 10:22
  Speaker 3: And so I think that the first thing that makes it challenging is that this isn't just one territory right, it's a lot of territories and inherently it has depth to it, right, like we're talking about soul wounds, and it also begs the need for interdisciplinary care.
• 10:41
  Speaker 3: So I co-facilitate the group that we have here, that Jeremiah, with Jeremiah Richards, who is my amazing chaplain counterpart and I wouldn't do this work without a chaplain, and I think he would say the same thing about having mental health as well, to kind of tag team it.
• 10:57
  Speaker 3: So I think it begs the need for interdisciplinary care.
• 11:01
  Speaker 3: I think one thing that makes moral injury difficult, relative to some other mental challenges as well, is kind of there's a sense of Valor in certain types of traumas, and we work with a lot of combat veterans and combat-related moral injuries, but it's just kind of a weird concept to actually sit and think about the thing that somebody got a medal for and accepting that could be and likely is in many cases, the same situations where somebody lost a brother or a sister, or some civilian died that shouldn't have died.
• 11:41
  Speaker 3: And there is a lot of situations, I think, in the civilian world and trying to bridge those, close those gaps, that can compound people's shame Like I'm accepting this parade, this 10% off at Applebee's and a thank you for your service and that can feel like its own type of betrayal because of the Valor associated with trauma in combat settings, right With that being said, the level of grief and loss is exceptionally high with our veterans.
• 12:20
  Speaker 3: I think most veterans, by the time they're 26, have dealt with more grief in their life than we on the civilian side would accrue in a lifetime.
• 12:32
  Speaker 3: And that in particular, that level of loss and grief is, I think, compounds that moral injury because it's so isolating.
• 12:42
  Speaker 3: And you know there's a line in Achilles in Vietnam that says I might be paraphrasing a little bit, but it's essentially, if you're not safe enough to sleep, you're not safe enough to grieve.
• 12:55
  Speaker 3: So you know, we have all these people who are coming back and they never got to grieve and that's it's sad, right, we have a whole society of grief.
• 13:12
  Speaker 3: I think that's a particular challenge with moral injury and I think the perpetrator piece of that can also be really challenging, right.
• 13:22
  Speaker 3: Helping people connect with this question of how do I honor those who were hurt because of me, even if you didn't do something directly, right, even if you just bear witness to something being involved, feels like guilt enough for a lot of people.
• 13:41
  Speaker 3: And so I think, yeah, like that, how do I honor those who were hurt because of me?
• 13:47
  Speaker 3: And approaching that versus avoiding it, which is a big work.
• 13:53
  Speaker 3: This is a big part of working with shame, which is not a part of all mental health things.
• 13:59
  Speaker 3: Right, as people, we all can tap into that.
• 14:03
  Speaker 3: But, yeah, so just some thoughts.
• 14:06
  Speaker 3: And oh, and the last one I was going to say is I think another thing that can compound it or be like extra challenging for moral injury is this chasm, right, that is often present between veterans and civilians in the country, because there's a not knowing right.
• 14:27
  Speaker 3: There is a need for the community to take a role and to take responsibility in carrying the burden of the people who go to war on our be halves, and there's something about the not knowing.
• 14:40
  Speaker 3: That, I think, makes it to where you know.
• 14:45
  Speaker 3: When people say and I don't say this to people, but I don't know when people say thank you for your service, people with moral injury.
• 14:53
  Speaker 3: Often it's like this response of you have no clue what you're thanking me for, because if you did, you wouldn't be thanking me, right Like we're drawing attention to something that relates to their brokenness, and I think that that is really hard to navigate around as well.
• 15:14
  Speaker 4: We talked about that particular piece, I think Jamie and I did recently, about thank you for your service, and I think because it's tough right, because people want to express their appreciation to veterans and they don't know what else to say, and so their heart is beautiful that you know people thank me for my service all the time.
• 15:39
  Speaker 4: I really appreciate it and I but I'm not in the category where I have shame about anything I've done.
• 15:47
  Speaker 4: I don't, I don't like the hero.
• 15:49
  Speaker 4: People say you're a hero because I don't see myself that that way at all, but I think one one way we could do that that maybe we can educate people on civilians, on I'm not saying they have a class about it, but if, if somebody were to say to me, even if I did have some guilt for what I did, but thank you for your willingness to serve, thank you for your willingness to you know, it's a little bit of a different message, at least in the sense that your willingness was honorable, no matter what actually occurred over there.
• 16:22
  Speaker 4: But but that's a tricky one, very tricky.
• 16:26
  Speaker 3: Yeah, and I think it's different in our country because, at least you know, for a really long time the last several wars have not been fought here.
• 16:35
  Speaker 3: You know, and I, you know, I have family in Lebanon, in Beirut, and like my uncles, fought in the military for Lebanon and there, when you go over there, still to this day, you know, like you have like the armed forces, you know all over the country, and there's this cultural norm that when you pass through you say yeah, I think when it off you, which translates I think kind of loosely to this, like like may God give you, may God give you the will to keep doing what you're doing, because in Lebanon, for example, like they fought the wars on their soil, so the civilians know what the soldiers do.
• 17:14
  Speaker 3: Here there is a not knowing that is painful, right, it's painful for people because they don't know, and that's not their fault, right.
• 17:26
  Speaker 3: And it's our responsibility to find places and avenues, and education, like he said, to try to figure out how to hold the experiences, so the people who bear the weight of them are not just our veterans.
• 17:43
  Speaker 3: Yeah, one, and I go ahead, Jamie.
• 17:50
  Speaker 2: No, please go ahead and I'll jump in.
• 17:54
  Speaker 3: Okay, I was going to.
• 17:55
  Speaker 3: Well, it was actually a separate thought.
• 17:56
  Speaker 3: So if you want to add to that, I'll go.
• 17:59
  Speaker 2: You, you you talked about something and it just hit me different today, like there's the bearing witness to the things that, like maybe you didn't do anything or like I wasn't in my personal journey with this.
• 18:19
  Speaker 2: It definitely affected me.
• 18:24
  Speaker 2: But then, even within the veteran community, it feels weak to say, oh, my feelings were hurt or my soul was wounded by these things that I observed when there's people that actually had limbs blown off, and then you're like comparing and you're hesitant to share because your thing feels dumb compared to their thing, and so I think there's even this compounding effect of the moral injury in that it doesn't feel worthy of being labeled an injury.
• 18:58
  Speaker 2: Does that make sense?
• 19:00
  Speaker 2: Yeah?
• 19:01
  Speaker 3: Yeah, and I think that's the shame piece of it, right, because the thing that shame wants everybody to do is to hide and to isolate, and shame festers in isolation, it grows there.
• 19:14
  Speaker 3: A lot of those same people would say I would trade this shame for my left leg any day to make it external, to make people see that it's valid.
• 19:27
  Speaker 3: I would give that up, right.
• 19:29
  Speaker 3: So I think it's six on one, half a dozen on the other.
• 19:34
  Speaker 2: Still, yeah, that's interesting Thanks.
• 19:39
  Speaker 3: I think the big thing to Jamie is that it's helping people bearing witness to is what heals right.
• 19:48
  Speaker 3: So it's helping people recognize that in and of itself, inherently, they are worthy and inherently their story is valid, without this need to justify.
• 19:59
  Speaker 3: But we grow up in a society.
• 20:01
  Speaker 3: A lot of times and a lot of us I'll speak for myself have these perfectionistic tendencies where it's like, if I'm not understood, I don't think that it's valid until this other person sees it as valid right.
• 20:12
  Speaker 3: And I think part of healing is recognizing that there is this inherent goodness and humanity that we must restore as providers and as civilians and as a society.
• 20:24
  Speaker 3: And you can't do that without holding people's stories and giving them respect, regardless of if it is something that you can visibly see or not.
• 20:36
  Speaker 3: You're not the judge, you're not the decider of what's valid.
• 20:39
  Speaker 3: So that's the cool part about it is that we just have to help people do that with this belief that it is inherently valid.
• 20:49
  Speaker 3: So it's easier than it might sound right and having to justify.
• 20:58
  Speaker 2: Right, yeah, I appreciate that.
• 21:00
  Speaker 2: Thank you yeah.
• 21:02
  Speaker 3: The other comment I wanted to make on this question of the challenges with working with moral injury, kind of related to all the realms that it goes through, is that, unlike a lot of other kind of mental health quote, unquote diagnoses, even though it's not, there's no protocol or anything right.
• 21:22
  Speaker 3: So there's so many amazing approaches developing in the provision of moral injury care across the country right now, but it's relatively, it's in its infancy.
• 21:33
  Speaker 3: So we need more people, more training, more providers, more money right to delve into this and I think to be intentional about how to spread that word to also protect the sanctity of that work.
• 21:50
  Speaker 3: I you know there's a lot of like I say this facetiously, but like, kind of like.
• 21:57
  Speaker 3: There's a lot of things, I will say, in the therapy world that are very like, manualized, and have a lot of incredible research and helpfulness behind them and I would be cautious to judge how people heal in the realm of moral injury with the same standards as something.
• 22:16
  Speaker 3: So what I think reductionistic as symptom severity, like it's more than that right.
• 22:22
  Speaker 3: Like, how do you measure resilience?
• 22:24
  Speaker 3: How do you measure post-traumatic growth?
• 22:25
  Speaker 3: How do you measure the ability for somebody to believe that they're worthy of forgiveness?
• 22:31
  Speaker 3: Like, how do we capture these things, and so I think that that's a challenge.
• 22:36
  Speaker 3: Right Is that we are still trying to figure out what approach and what lens or approaches and lenses we want to come at this with in a way that honors people's experiences and what is needed for healing, and there's a lot of amazing work that's going on right now and trying to disseminate that.
• 23:01
  Speaker 3: You know, what we do here is one approach, and that's it right, and so I think that that's a big part of it is that it's still in its infancy in how we are trying to develop the care.
• 23:21
  Speaker 1: Like that's my personal goal too with the podcast, so hopefully that will help as well, and I know you've had experience with helping people process their moral injury inside of group therapy.
• 23:33
  Speaker 1: I'd love to hear your perspective on group therapy versus individual therapy when it comes to moral injury and also, like, how would that work if you're working with, like an introverted person?
• 23:45
  Speaker 1: Like you think it's better for them to like be in that group setting?
• 23:50
  Speaker 1: Like, do you think that helps them better?
• 23:53
  Speaker 3: Oh yeah, oh yeah, I 100% group, group, group, all the way.
• 23:58
  Speaker 3: There is this idea right that, if that it's, what book is it from?
• 24:09
  Speaker 3: I think it's from the perks of being no the fault in our stars.
• 24:14
  Speaker 3: There's a book that Jeremiah always quotes in group and there's a line in it that says pain demands to be heard.
• 24:21
  Speaker 3: Pain demands to be heard, and we know self-disclosure is really really important in healing and it's been.
• 24:31
  Speaker 3: You know that there's that recent Amanda Cahn and Shira Megan and one of their colleagues article that had come out here just in 2023 that we were reviewing just over this past week, and there I mean all of these things that we know are helpful are actually showing up in the literature more over these last several years, and so self-disclosure and trust and bearing witness to are all really important for shame, to help lift shame.
• 25:00
  Speaker 3: And when you're in a group, setting right like, you're around people who remind you that you're not alone, which opposes shame and you are around people who, hopefully, are responding in ways that are compassionate and respectful and that, like witness your humanity despite the thing that you feel like destroyed it or countered it or has eroded it over time.
• 25:28
  Speaker 3: And I think that the power of the group, the power of the response, the power of the bearing witness to, is something that you cannot replicate individually.
• 25:39
  Speaker 3: It's also why community is really important for healing, and people don't heal in isolation, and shame doesn't heal in isolation, and so you know, developing that trust is super key.
• 25:54
  Speaker 3: And the other quote that I always, just I adore, by Anne Voskamp.
• 25:58
  Speaker 3: She says shame dies when stories are told in safe places.
• 26:02
  Speaker 3: So when you are in a group and you hear somebody say like this is the first time in 50 years, I've said this and instead of it being met with criticism and judgment and all the things that, like their anxiety and their fear, tells them it will be met with, and it's just met with non-judgment or kindness, or like I see you.
• 26:27
  Speaker 3: Despite this, and I'm sorry you had to make that choice, there's something healing about that, and so I would.
• 26:35
  Speaker 3: I could go on forever about this.
• 26:37
  Speaker 3: I would fullheartedly.
• 26:39
  Speaker 3: Yeah, it doesn't matter if you're shy, extra, I mean.
• 26:43
  Speaker 3: Whatever it is like, healing happens when there's community around you, especially because moral injury has so many social wounds to it.
• 26:54
  Speaker 4: So, on that piece right when you have you encountered someone that is so locked up that that they that they couldn't even consider saying that in a group and, if so, how do you kind of get them to first try a group?
• 27:15
  Speaker 4: I'm thinking of a client on my own in particular that was just really locked up inside and, you know, had spent her whole life not trusting anyone, feeling like she had to do it on her own, etc, etc.
• 27:31
  Speaker 4: Have you encountered that and how?
• 27:35
  Speaker 4: How did you help that person?
• 27:37
  Speaker 4: Just try a group, get in a group, just start.
• 27:41
  Speaker 3: Yeah, that's a great question, Dr Roberts.
• 27:43
  Speaker 3: I think the first thing, my first inclination, is this this balance, or this struggle of trying to strike a balance with, like meeting them where they're at, because people live their way into the answers when they're ready.
• 27:55
  Speaker 3: And, you know, not all groups are good groups, not all facilitators are able to, you know.
• 28:04
  Speaker 3: So I think, like if there is a way individually, where you can help give somebody the language, because that's the first thing that people struggle with, I've noticed, is we don't have a lot of language for how to describe these things.
• 28:20
  Speaker 3: So if I asked somebody about how would you define grief and they said, oh well, you know, when somebody dies and you have feelings about it, it's like, oh my gosh, like that is the tip of the iceberg when we think about grief and loss and lament and all of these related things, I would see if it's like helpful to like you know, sometimes giving people books to go through can help people develop the language.
• 28:45
  Speaker 3: To be like this resonated with me.
• 28:47
  Speaker 3: Or to ask about, like what, what purpose does this serve in your life?
• 28:53
  Speaker 3: Because sometimes people hang on to things because it still does something for them, it still works for them.
• 28:59
  Speaker 3: It doesn't mean that it's helpful, but if it still works, they're not going to let it go until it doesn't anymore, you know.
• 29:08
  Speaker 3: And so I think that that's a hard part.
• 29:11
  Speaker 3: But taking the other end of the perspective, there is like how does it still serve you?
• 29:16
  Speaker 3: How is it still protecting you, to protect this part of yourself?
• 29:19
  Speaker 3: And maybe what is it costing you to hold it so tightly?
• 29:23
  Speaker 3: What would it mean to hold it in a different way?
• 29:29
  Speaker 3: Or what would it mean to unpack it or write it down or tell somebody, like I think some of those like really open, exploratory questions that are just you're just curious and non-judgmental, like I think that that's always a good starting place.
• 29:47
  Speaker 3: Some people aren't group people and I get that, but it is a dance, I think, and trying to not convince people but to help them recognize that you're uncomfortable because of this risk, and healing doesn't happen without risk, safe risk.
• 30:13
  Speaker 3: You could always start with an easy coping skills not easy, but easy emotionally coping skills group where they're not asked to talk about how they're feeling or what they've been through, it's just skills.
• 30:25
  Speaker 3: Then they can recognize okay, I can be in a setting like this, this is okay.
• 30:29
  Speaker 3: Or if they know the facilitator.
• 30:33
  Speaker 3: I invite some of my veterans individually who are like hell, no, I'm not touching that group with a 10-foot pole.
• 30:41
  Speaker 3: I'll invite them to the healing ceremony because they get to see the end of the men and women who have gone through the group.
• 30:49
  Speaker 3: Sometimes that can instill a little bit of hope that this person's story resonated with me, and if they can do this, maybe I can.
• 30:58
  Speaker 3: Then we just explore it with no pressure.
• 31:03
  Speaker 1: Do you think it's over?
• 31:06
  Speaker 1: Did you want to say something, Becca?
• 31:13
  Speaker 4: No, sorry, I was just going to say that's great answer, thank you.
• 31:18
  Speaker 1: Do you think it's possible to fully recover from rural injury?
• 31:24
  Speaker 3: Oh, Mante, what a question I would maybe think about.
• 31:33
  Speaker 3: How do we define the term recovery as an ongoing practice?
• 31:41
  Speaker 3: Healing is ongoing.
• 31:46
  Speaker 3: I wouldn't equate it to the absence of being impacted by what we have experienced.
• 31:55
  Speaker 3: I love that we can be multidisciplinary in how we see the depth in people's recovery journeys and being mindful and aware of the wound that we carry.
• 32:06
  Speaker 3: Yes, through the lens of post-traumatic growth, people heal.
• 32:16
  Speaker 3: I hesitate to use the word recovery because I don't want to come across as though there is a period where you stop trying, where it is as though you went into remission, so to speak.
• 32:33
  Speaker 3: The post-traumatic growth piece, I think, is a cool way to measure recovery as well.
• 32:36
  Speaker 3: A lot of the ways in which PTG or post-traumatic growth can be measured most simply is when people have this element of choice to live their lives in purposeful ways, that gets restored.
• 32:55
  Speaker 3: Sometimes that looks like better relationships or increased spiritual awareness or connectedness, more appreciation of life or personal strength, and openness is the other one.
• 33:10
  Speaker 3: When people live their lives in that way, it's not to say that they do not still carry wounds, it's just that those are the only things that define their life anymore.
• 33:25
  Speaker 3: They get to carry it in a different way.
• 33:27
  Speaker 3: It's not about getting rid of it, it's about carrying it differently.
• 33:34
  Speaker 2: I appreciate that, even as I reached out to Dan originally because I had been going through the VA mental health disability process to go through that and diagnosed with depression, which one of the things that I've loved by going through what we do here is learning that depression wasn't a mental health issue.
• 34:11
  Speaker 2: It was a healthy response to what I was going through.
• 34:16
  Speaker 2: That alone set me free on the oh, I was actually responding appropriately has really really helped To go back to my original point was just as I've been able to learn about ways that I can help others.
• 34:39
  Speaker 2: It has helped shift it from being about me and what happened to me into that informed the work that I'm doing.
• 34:49
  Speaker 2: I don't know if I ever want to completely let that go.
• 34:53
  Speaker 2: I don't want to forget what I experienced because it's going to water down what I do as I listen to people.
• 35:00
  Speaker 2: It does bring things up in me.
• 35:02
  Speaker 2: It does remind me of things that didn't feel good in the past.
• 35:06
  Speaker 2: But I have more tools.
• 35:08
  Speaker 2: I know that I've got a way to channel it into making other people's lives better.
• 35:13
  Speaker 2: It helps me get through the guilt and the shame and all that.
• 35:18
  Speaker 2: I don't think I feel guilt and shame.
• 35:20
  Speaker 2: I know that if I didn't have this positive outlet and this reframing of what moral injury and the way that it made me feel actually is, I wouldn't be where I am today.
• 35:34
  Speaker 2: That's definitely healing, but you don't really ever forget.
• 35:38
  Speaker 2: You can still tap into the way that it made you feel before.
• 35:42
  Speaker 2: You knew better.
• 35:44
  Speaker 3: Yeah, the way that I'm.
• 35:45
  Speaker 3: That's beautiful, jamie.
• 35:46
  Speaker 3: It's like it can be in the backseat of the car.
• 35:49
  Speaker 3: You just don't want it jumping in the front seat and driving.
• 35:53
  Speaker 3: Of course, it's the big thing from a moral injury perspective that I feel like is really important for people who doubt their worthiness because of how they feel or what they've gone through or how people have treated them.
• 36:07
  Speaker 3: A lot of people's moral injury, to be fair, starts in childhood.
• 36:12
  Speaker 3: It just keeps compounding and then the military Perhaps, all over it.
• 36:18
  Speaker 3: Sorry, we might have to edit that, but by literally, by definition, if you carry the pain, that is moral injury, you carry humanity and goodness, which is the thing that you don't think that you have, which is ironic.
• 36:35
  Speaker 3: I think that that's really, really important.
• 36:38
  Speaker 3: Is you carry this injury because of the goodness that you are and that you have and that you carry and that?
• 36:46
  Speaker 3: you are worthy of that healing.
• 36:48
  Speaker 3: That is at the very, very core of it is why, bearing witness to people's pain and just holding it and responding with non-judgment and respect, you can't fix it, you can't rest a little way, you can't unsteep the tea, like you said right, the point is not to forget.
• 37:06
  Speaker 3: The point is how can I live purposely and show up in meaningful ways in my life despite what I have been through?
• 37:13
  Speaker 3: That is, I would not say that is again that term of full recovery, because that seems finite, but that's healing for sure.
• 37:27
  Speaker 1: All right, and then could you share some examples of success stories where individuals have successfully I'll delete the recovered successfully healed from moral injury?
• 37:40
  Speaker 3: I love it.
• 37:41
  Speaker 3: I'll give you one, being mindful of time, a brief one.
• 37:45
  Speaker 3: I think again like kind of describing how I describe moral injury, is a bit of a shapeshifter.
• 37:51
  Speaker 3: I think healing can look the same right.
• 37:54
  Speaker 3: And we had somebody I'm trying to be mindful of identifying information here who was a fighter pilot and was involved in a situation where wrong intel was given and hundreds of people were killed civilians and it created on many, many levels a ripple effect of anti-American hatred and animosity among all of the people themselves that died, and his involvement in that for decades now has been carried deeply and in a very, very heavy way.
• 38:46
  Speaker 3: And so I think part of what this person's healing has looked like is in kind of ruminating less and seeking out reading about the thing that happened less on anniversaries, on Google, on all of these like kind of ruminative tendencies started to go down.
• 39:08
  Speaker 3: But more importantly, he found ways to like give back to his community.
• 39:12
  Speaker 3: So connection, courage and compassion are the three things that Bernay Brown talks about that really heal shame, like the opposite of what shame does, and so helping him connect with other veterans and giving back to his community through creative outlets, especially because war at best is destructive.
• 39:34
  Speaker 3: So, in the grand scheme of balancing out the scales with whatever you can, creating and connecting can really really help people, and giving back it kind of like how Jamie was saying, like shifting that focus into how do I channel this into something?
• 39:53
  Speaker 3: That means something which I know we'll get to here in a moment.
• 39:57
  Speaker 3: So I would say, like what his healing looked like is in shifting his attention from this thing, giving himself permission to be human, that this was not intended, and that he mourns and grieves the loss of those lives and can honor it in the ways that he can, and the rest is not his to carry and then to give back, and so that's what it looks like for him.
• 40:30
  Speaker 1: And in the case of where forgiveness played a role, can you share in general terms how you would know that person has reached that level or that state?
• 40:41
  Speaker 3: I have a Mante.
• 40:42
  Speaker 3: My answer for this is a non-answer.
• 40:44
  Speaker 3: I don't know how you know.
• 40:47
  Speaker 3: I think that the way that I see forgiveness and approach forgiveness is really with a lot of curiosity and a lot of openness and understanding, like what does that mean for somebody else, this giving up, giving over to?
• 41:02
  Speaker 3: I don't think it's realistic right to equate forgiveness with not being impacted by deeply painful moments in our lives.
• 41:10
  Speaker 3: But I do think it's realistic to recognize that it is this process of continuous choosing to let go right versus just this one-time thing, and I think through that people start to reclaim themselves again and it can start to restore that sense of humanity, and so I think it does play a really large role.
• 41:35
  Speaker 3: After you address shame.
• 41:36
  Speaker 3: So I don't, I can't think of an example where somebody where shame has not lifted at least a little bit its grasps and then forgiveness seems like a possibility for that person.
• 41:48
  Speaker 3: The analogy I think of is this idea that a light, lightness and darkness can't occupy the same space at the same time.
• 41:57
  Speaker 3: So when we are able to shed light on shame, it starts to lift itself right and then, as it starts to lift, worthiness creeps in and when people believe on some level, even a little bit, and they are treated as such, that they are worthy of forgiveness, that they are worthy of connection and love and compassion and all these things that we know are associated with healing.
• 42:25
  Speaker 3: They tend to consider.
• 42:27
  Speaker 3: They tend to consider that more.
• 42:30
  Speaker 3: So what we do in our group is one of the first things we do is talk about the myths of forgiveness.
• 42:36
  Speaker 3: What does it mean?
• 42:38
  Speaker 3: What does it not mean?
• 42:39
  Speaker 3: Doesn't mean forgetting, kind of like what Jamie highlighted earlier and parallel concepts.
• 42:44
  Speaker 3: So atonement, right, reconciliation.
• 42:47
  Speaker 3: You know these are different things that have parallel paths.
• 42:51
  Speaker 3: But I tend to see forgiveness as a byproduct of worthiness and shamelifting as opposed to like a thing to pursue in and of itself.
• 43:06
  Speaker 3: And you know, jeremiah always has the idea of like, no cheap grace, like, and I have a feeling that that is like super impacted by his time in the church, where people and veterans in particular, have a high need to take responsibility where responsibility is due and they will have theirs to carry and you have to let them carry it right.
• 43:31
  Speaker 3: You can't go through mental gymnastics and redistribute responsibility or blame or whatever and try and hope to try to make somebody feel better, because you're missing on the cultural value there, which is I will carry the burden that is mine.
• 43:46
  Speaker 3: So acknowledging your part in something, I think, has to preface that, which is why it's like no cheap grace, like I'm not going to just do, like say I'm going to do this thing without putting the work in prior.
• 44:02
  Speaker 3: I think a lot of veterans have difficulty with this topic If they equate it to getting like letting themselves off the hook, right.
• 44:16
  Speaker 3: So if you carry a lot of guilt with you or grief with you, sometimes people equate forgiveness with dismissing responsibility, right, and that's the opposite of what we want.
• 44:27
  Speaker 3: So that's why it's so important to just talk about what does this mean?
• 44:32
  Speaker 3: Because what keeps people stuck oftentimes is this idea that if I forgive, then does that mean that I don't care anymore or does that mean that I'm not thinking about this person anymore?
• 44:47
  Speaker 3: What does it mean?
• 44:48
  Speaker 3: So, I think, recognizing some of the barriers to that and balancing again this how do I honor those who were hurt because of me?
• 44:59
  Speaker 3: And how has carrying this in this way hurt you?
• 45:02
  Speaker 3: Because, again, if people don't recognize that they have the power to forgive, right, they don't see themselves as having authority.
• 45:14
  Speaker 3: Then they're kind of at the mercy or the grace of others, which oftentimes it's self forgiveness where a lot of the work lies.
• 45:26
  Speaker 3: So it's kind of tricky, it's very tricky, I think I struggle with it all the time.
• 45:31
  Speaker 4: Yeah, I know we're running short on time, but so within that related to that, do you find it useful to talk through with people how much responsibility they actually do have?
• 45:47
  Speaker 4: For instance, my friend Airborne Ranger had moral injury from the combat things he did, but because women and children got killed often in what they were doing, but they were also never provided the appropriate information to make decisions right.
• 46:09
  Speaker 4: So they went into buildings in a very kinetic way right, throwing hand grenades in, throwing saps of charges in, because they were told it's a free fire zone, it's all bad guys.
• 46:21
  Speaker 4: There are no innocent people in that building to find out later that wasn't true.
• 46:27
  Speaker 4: Right, they were responsible for killing people, but they would have never done that had they known they were women and children.
• 46:36
  Speaker 4: They were given bad intel, right?
• 46:38
  Speaker 4: So is that a case where you might talk through what they were actually responsible for, In the sense you behaved honorably in that you followed the rules, engagement, except you were given bad information?
• 46:54
  Speaker 4: Or something bad pieces.
• 46:56
  Speaker 4: Is that somehow you might talk through that?
• 46:59
  Speaker 3: Totally, totally.
• 47:01
  Speaker 3: I think that it's really hard when you're in situations where there's perpetrator and betrayal because getting bad intel is betrayal to people right, because there's grief and sadness in that you were put in a position where the choice that you had to make was one that is going to compromise you for the rest of your life.
• 47:26
  Speaker 3: That right there you know, doing the responsibility pie, like from adaptive disclosure, we use it all, I feel like it's quite common, but can be helpful sometimes in just right sizing the responsibility, and we just recently did this with our group and it was interesting how many people came back with US government as more to soak up more of something than like Taliban.
• 47:53
  Speaker 3: And so I think that the biggest struggle in cases like that though, dr Roberts, is you can wrestle away factually and rationally that you're not responsible for all of these deaths, and maybe you only have, maybe you give yourself 20% responsibility.
• 48:18
  Speaker 3: But the question becomes but how do you carry that 20%?
• 48:24
  Speaker 3: How do you and I think that's where grief how do I honor those who were hurt because of me?
• 48:30
  Speaker 3: How you answer that question right, how you live that question out matters, and I think the self-forgiveness piece I always think of this quote from Maya Angelou that says forgive yourself for not knowing what you didn't know before you learned it.
• 48:47
  Speaker 3: People make the best choices they can with what they have at the time, and that is barring situations that are such high pressure and high stakes.
• 49:01
  Speaker 3: And when you add those variables, I mean I don't envy making a single choice like that and to have to live with that.
• 49:10
  Speaker 3: But I do think there's something about how do I honor those who were hurt because of me and having that piece of grief and that acknowledgement that, because you are hurting, it reflects your care, it reflects your humanity, and to honor that too, and then the self-forgiveness piece might come into play, because, yeah, the bad intel piece, I feel like, is a really common part there.
• 49:39
  Speaker 3: That's painful.
• 49:42
  Speaker 1: All right, so I think it's time for one more question.
• 49:45
  Speaker 1: So in your PowerPoint you stated that with interventions for forgiveness there is meaning making, amends, speaking action, honoring and meaning making.
• 49:57
  Speaker 1: Could you elaborate on the meaning making and aspect of forgiveness?
• 50:04
  Speaker 3: Yeah, I think of, like Frankel and Nietzsche here, right, where the Frankel has this, instead of this will to survive, it's the will to meaning, and Nietzsche has the historic.
• 50:19
  Speaker 3: He who can find a why to live can bear with almost anyhow.
• 50:22
  Speaker 3: So attributing meaning to situations where there's pain or there were otherwise feels meaningless can help counter this sense of it being in vain.
• 50:35
  Speaker 3: And a lot of our veterans, I feel like, struggle with this idea that like this is in vain and then it doesn't mean anything if it's in vain, right.
• 50:46
  Speaker 3: And so I think this idea that what asking the question like what does this pain have to teach me and how can I listen to that in it for a lot of people ends up shifting and to their values.
• 51:01
  Speaker 3: How do I reconnect with the values?
• 51:03
  Speaker 3: How do I instill the some of these values that I that resonate with me in my children?
• 51:10
  Speaker 3: How do I give back this existential question of why we hear so often and it is a painful question to ask because it doesn't really have an answer, you know, like doesn't, doesn't have an easy answer and it doesn't direct people.
• 51:26
  Speaker 3: So if somebody says like why him and not me, for example, you can't answer it right.
• 51:34
  Speaker 3: But maybe start with a different question how can I honor this loss?
• 51:41
  Speaker 3: What can I do to write to their family and hold that person in my in remembering?
• 51:49
  Speaker 3: Right, because veterans care about honoring people and honoring the things that that mean something to them, right?
• 51:56
  Speaker 3: You can't honor things that you avoid.
• 51:58
  Speaker 3: So finding ways to recognize that people live in the remembering can give meaning to that pain, and it might not.
• 52:09
  Speaker 3: It's not going to take it away, but it makes it more livable, more sustainable, meaning Trump's happiness any day, right.
• 52:17
  Speaker 3: And there's this idea that you know, like reconnecting with your values is something that we talk about in group and your values are like a compass, like you can go east but you don't arrive at east.
• 52:30
  Speaker 3: You never arrive at east.
• 52:32
  Speaker 3: Like you just follow that direction and you're in a new position and you follow that direction, and so I think that that's important to help get people connected with and even you know I'm thinking of like instilling things in your children or even just having these difficult conversations.
• 52:48
  Speaker 3: I met a veteran one time come to session and he said Amanda, I walked into my son's room, who was like eight or nine at the time and he was playing war and it was just so it was interesting, but it was difficult to hear, like how he was just trying to navigate in a very like age appropriate way, how to talk to his kid about like I don't want you to play war and like let's talk about what that means.
• 53:23
  Speaker 3: To think twice about glorifying and heroizing or pathologizing the veteran community.
• 53:30
  Speaker 3: That happens right To kind of fall in line with what we as a community tend to do, and so something so simple is that gives his service meaning because he's passing down thoughtfulness to the next generation that's gonna think twice before maybe they vote somebody who's gonna send people over there or before they do whatever.
• 53:54
  Speaker 3: So I think that the meaning making piece is so important in giving back and in recognizing the lessons that pain has so it's not in vain and in helping people kind of show up in meaningful ways in their life, because doing so does not require pain to be absent.
• 54:17
  Speaker 3: And I think that's the big thing here.
• 54:20
  Speaker 3: Right Is like you can still experience pain because that is part of your humanity that we share, like that is common, and I can still go to my kids soccer game and I carry that with me and hopefully carry it in a lighter way or unpack it or put wheels under it like something, and yeah, so the meaning piece is just clutch.
• 54:43
  Speaker 3: I think, when it comes to healing, that it meant something.
• 54:47
  Speaker 3: So, amanda, so thank you so much for your time.
• 54:53
  Speaker 4: It's been a great, great session and I mean the depth of your knowledge, the passion that you have for veterans and helping them and just the great programs you guys are doing their Asheville VA and I think that's the big thing that we're doing in our lives and I think that's the big thing that we're doing in our VA.
• 55:19
  Speaker 4: I'm very proud to know you that we've worked together over the past several years for our conference and stuff, but just having you on the podcast today has been really fantastic and I appreciate it.
• 55:32
  Speaker 3: Yeah, thanks for having me, guys.
• 55:33
  Speaker 3: I feel like we could just chat all day about this stuff, you could?
• 55:38
  Speaker 1: I definitely do.
• 55:39
  Speaker 2: I might circle back with you, amanda, and learn more about the program that you're doing with a psychologist.
• 55:44
  Speaker 2: Is that?
• 55:44
  Speaker 2: I don't think that's done in every VA, but it sounds like something that would be very beneficial, and so I'd love to learn more.
• 55:52
  Speaker 3: So thank you yeah totally Wonderful wonderful.
• 55:55
  Speaker 3: Yeah.
• 55:56
  Speaker 2: It made me feel better, even better.
• 55:59
  Speaker 3: Good.
• 56:00
  Speaker 3: Well, I appreciate the work that y'all are doing, and I mean it's.
• 56:03
  Speaker 3: It always goes back to, like, the need for more right, like we need to capitalize on that momentum and keep advocating and getting it out there and protecting that work right, because putting, you know, putting somebody in a position where they're responsible for, like the provision of care for veterans who have been morally injured or carry moral injury, is a delicate thing that we need to protect, because the consequence of saying something that reinforces something that is not helpful or healthy, it could be the difference between, you know, that person waiting 40 years to be in your office and never coming back again.
• 56:49
  Speaker 3: And so I think we need to recognize the depth and the need for this care, to keep developing it, and there's a lot of wonderful things that are happening to do that and I hope it'll continue.
• 57:06
  Speaker 1: All right, and to those who are saying thank you so much for joining us on this episode and thank you again so much, dr Amanda Yuck.
• 57:13
  Speaker 1: And we're gonna just end the episode with some final words, encouraging words from Dan and Jamie for any listeners, especially veterans and families who may be navigating through the challenges of moral injury.
• 57:31
  Speaker 4: Thanks so much again.
• 57:32
  Speaker 4: Thank you, amanda, and we'll continue on this podcast to have other guests and through our conference and our books and other things that we do.
• 57:44
  Speaker 4: But we'll, I just encourage, if you're a veteran, you know this podcast we're not doing therapy, we're just introducing people to ideas and stuff.
• 58:00
  Speaker 4: But you know, my encouragement to you is that Amanda's one great example of a group of people and practitioners that are really, you know, doing great work to help veterans with moral injury.
• 58:19
  Speaker 4: But there are many others out there.
• 58:20
  Speaker 4: So you can reach out to us at missions m-i-s-n-sorg or you can contact our phone number, 901-701-0306.
• 58:32
  Speaker 4: If you need some help finding a group or a session, a program that can help, you because there's a lot out there and a lot of different approaches that people are taking.
• 58:48
  Speaker 4: So again, I would just encourage you to reach out to us if you don't know of a program.
• 58:53
  Speaker 4: If you have heard of a program, I would just say give it a try.
• 58:57
  Speaker 4: You know, talk to them, see what their approach are taking and, you know, start getting some help.
• 59:10
  Speaker 2: I don't really have anything to add to that, monta.
• 59:12
  Speaker 2: So thank you again.
• 59:14
  Speaker 2: Thank you, have a good night.
• 59:21
  Speaker 2: Thank you, yeah.