Moral Injury; interventions for First reSponders City of Scottsdale Police Department Sgt. Michael Hanafin, #582 Natalie Summit LPC; Retired Police crisis Interventionist, #B815

Objectives Encourage participants to think and engage a different way of exploring trauma in the Public Safety setting Introduce Moral Injury Compare Moral Injury to PTSD Identify the Moral Injury connection to Veterans and First Responders Explore therapuetic interventions when addressing moral injury.

2017-2018 - CIT Officer Dan Antrim and Natalie Summit 2019 - Welcome Sgt. Hanafin!

Tribal Warriors “Soldiers experience this tribal way of thinking at war, but when they come home they realize that the tribe they were actually fighting for wasn’t their country, it was their unit. It makes absolutely no sense to make sacrifices for a group that itself isn’t willing to make sacrifices for you. That is the position American soldiers have been in for the past decade and a half.” -Sebastian Junger, Tribe Acting in a tribal way simply means being willing to make a substantial sacrifice for your community – be that your neighborhood, your workplace, or your entire country.

Encouragement: Be an independent thinker (for the next hour)

What Does It Mean To Be Moral? Moral - of or relating to principles of right and wrong in behavior Moral Judgments - expressing or teaching conforming sanctioned by operating on one’s one moral position. “Puppies and Babies are “precious” breathing living beings” Moral/Value: Hurting puppies and babies is bad.

Moral Injury Results when individuals violate their core moral beliefs, AND in evaluating their behavior negatively, they feel they no longer live in a reliable, meaningful world and can no longer be regarded as decent human.

Genesis of Moral Injury: “We all feel occasional guilt or shame for something we did, but war can require extreme actions that violate the very basis of moral identity. The life-or-death urgency of war forces untenable actions that can elicit profound guilt or shame. When we feel that what we did was wrong or unforgivable and that our lives and our meaning system no longer make sense, our reason for living is in tatters. This shattering of the soul challenges what holds life together and the anguish of moral injury begins.” --Dr. Rita Nakashima Brock, Soul Repair

How does this happen? Thinking, preparing, or committing to do what is valued as an immoral act Failing to act in a morally correct way due to cowardice or being ordered not to act and bad things happen Failing to prevent others’ seriously immoral acts. Possibly witnessing the act itself without the persons’ knowledge Seeing and/or hearing about someone else violating or betraying a core moral value. Failing to report knowledge of a sexual assault committed against oneself or another

How does this happen (continued)? Feeling betrayed by persons in authority and command staff watches in silence Giving orders in Public Safety that result in the injury or death of a fellow officer, civilian, child or animal and receive an award Witnessing a friend get killed or hurt in the line of duty and you survive Thinking “I got this!” and then knowing that “I am powerless” resulting in suicide Abandonment and disillusionment from within

Consequences of Moral Injury Overwhelming Moral feelings of guilt, shame, despair, angst, remorse, anger, outrage, grief, disgust, worthlessness, demoralization, self-condemnation, and betrayal Feel as though they lost their soul and are no longer who they once were Abandon the values and beliefs that gave their lives meaning and guided their moral choices. Decide no one can be trusted and isolate themselves from others Take their own lives in order to eliminate the shame and guilt and despair: “Its torments to the soul can make death a mercy.”

Moral Injury is Different than PTSD PTSD Moral Injury “Startle” Reflex Memory Loss Fear Flashbacks Hypervigilance Sorrow Grief Regret Shame Alienation Anger Depression Anxiety Insomnia Nightmares Self Medication Intense Fear Reaction Core Moral Beliefs Violated A diagnosis is a set of symptoms that meet a criteria. PTSD is a diagnosis. Reimbursable through insurance companies. Moral injury is not a diagnosis. Nash, Bill & Woods, D., “Moral Injury,” Huffington Post, March 18 2014

treatable and possibly curable? When two people face each other with an open mind, a clean heart and clear intentions to truly listen to another’s experience. The listener need not respond unless prompted. That is when we can heal and offer healing to another. This picture comes from that same camping trip… this tree is healing itself surrounded by a supportivenatural environment. Mike…

Moral Injury Treatments Sgt. Michael Hanafin #582 Scottsdale PD LAC MAPC MEd

Evidence Based Treatments Cognitive Processing Therapy and Prolonged Exposure Therapy are two most popular EBT used Even after EBT, 60-72% of combat veterans continue to meet dx for PTSD Cognitive Processing Therapy and Prolonged Exposure Therapy are two most popular EBT used Eye Movement Desensitization and Reprocessing (EMDR) Eye movement and focus help clients address specific traumatic incidents. EMDR uses desensitizing and reprocessing techniques while simultaneously using eye movement and focusing while the client is telling their trauma story. Stress Inoculation Training (SIT) This treatment focuses on help with coping skills. Relaxation training is an important component to address anxiety and fear. Breathing exercises are also learned as an important part of relaxation. Assertiveness training is used to help clients learn how to practically express emotions Prolonged Exposure (PE) One of the symptoms of PTSD is avoidance. PE involves telling one’s trauma story repeatedly over time. Part of the treatment also includes learning how and practicing reintroduction into those places and events which are triggering even though not traumatic. PE works by helping individuals limit problematic avoidance through gradual, systematic exposure to feared but safe stimuli (e.g., places, situations, memories). Essentially, PE helps individuals face their fears safely. PE involves two types of exposure: imaginal exposure and in vivo exposure. During imaginal exposure, individuals retell the trauma memory. The major goal of imaginal exposure is to help individuals emotionally process the trauma memory in order to reduce PTSD symptoms. By repeatedly telling the trauma narrative, individuals better organize and process the memory and their cognitive and emotional reactions to it. Cognitive Processing Therapy (CPT) CPT focuses on writing about one’s traumatic experience. Often those who have a traumatic experience become focused on beliefs about the trauma and its meaning that become distorted when experiencing life after the trauma. This treatment helps challenge assumptions and helps the client recognize and correct distorted thoughts and feelings. (https://www.veteranslaw.com/evidence-based-treatment-for-ptsd/) The primary focus of CPT is to modify dysfunctional cognitions that impair functioning, known as “stuck points.” For example, the “just world belief” states that, “good things happen to good people, and bad things happen to bad people.” If that is believed to be true, it can be hard for trauma survivors to make sense of why something bad happened to them and may impact their ability to engage in their lives as they did before the trauma. CPT challenges stuck points by teaching individuals how to assess whether facts support their stuck points. If not, they can work with their therapist to create a new perspective. CPT is believed to work by developing more balanced and helpful beliefs which decrease difficult emotions and other PTSD symptoms.7

Treatment - Moral Injury Since Moral Injury is overwhelming feelings of guilt, shame, despair, angst, remorse, anger, outrage, grief, disgust, worthlessness, demoralization, self-condemnation, and betrayal caused by abandoning the values and beliefs that gave their lives meaning and guided their moral choices or betrayal and they feel as though they lost their soul, are no longer who they once were and that no one can be trusted so they isolate themselves from others In PTSD the subject is a victim. In moral injury, the person is the accuser, of self or others. Betrayal is a core component of moral injury in police officers. Think of those who are involved in an OIS. They feel betrayed by their administration through silence, victimized a second time by the court system. Etc. The world of trust worthy people shrinks. Moral Injury is similar to Moral Distress, but they are not Identical. Moral Injury refers to violence and death related incidents. Moral Distress refers to moral dilemmas experienced by multiple mundane incidents that frontline professionals may frequently experience in the line of duty. Moral Suffering is both or either Moral Injury and Moral Distress

10 Theoretically-Grounded Dimensions of Moral Injury 1.) Guilt 2.) Shame 3.) Betrayal by Others 4.) Moral Concerns 5.) Loss of meaning/Purpose 6.) difficulty Forgiving 7.) Loss of Trust 8.) Self-Condemnation 9.) Spiritual/Religious Struggles 10.) Loss of Religious Faith/Hope 1-8 Psychological 9-10 Religious/Spiritual Measuring Symptoms of Moral Injury in Veterans and Acitve Duty Military with PTSD Harold Koenig M.D.

Treatment Then the questions for treatment become. What is the soul? How was it lost? How can it be regained? How were deeply held values lost? How can they be regained? Should they be regained? How was basic trust in others lost? Can it be rebuilt? Should it be rebuilt? Can someone “like” themselves again after having violated their core beliefs?

Soul Usually a question for religion Etymologically Psychology is the study of the psyche meaning spirit or soul.

Maslow’s Hierarchy of Needs Freedom Meaninglessness Isolation Shows a progression or development. Faith (Fowler) develops in stages, as does Morality (Kolberg). The mind which judges the behavior is not the same mind that engaged in the behavior. Death

Summary of the Soul Each is saying the same thing. The “Soul” is the unique part of the individual that must be expressed for the person to be a fully alive, fully formed person. It is done through discovery and enactment.

VALUES What’s important? Meaning.

How are deeply held values lost? Did you have these values to begin with? Are you really upset you violated these values, or are you worried others won’t accept you if they know you what you did? (Shame or Guilt?) Could you have resisted the influence of Authority, Environment, or Peer Pressure? Stanley Milgram Solomon Asch Philip Zimbardo Robert Cialdini You might have gone to war thinking you don’t kill women and children, but later discovered you are willing to, what you originally meant was you don’t purposely kill innocent individuals. Interestingly, those who have high moral standards are most at risk for moral injury because their standards are so high. “Life is pain, whoever tells you differently is selling something” Dread Pirate Robert

Betrayal of Trust Guilt: The function of guilt is to reconcile a damaged social bond. Shame: The reaction is to withdraw so the social group can preserve its identity. Someone betrayed you, or you betrayed someone Can you trust again? Should you trust again? Knowing your own darkness is the best method for dealing with the darknesses of other people. Jung (See Tribe) Shame: Trauma Related Guilt Inventory

Formalized Therapies Developed with veterans in mind, but with minor alterations can be adapted to first responders.

Four Foundational Assumptions 1.) The individual’s system of moral belief can be injured as well as repaired. 2.) Repair occurs along two pathways Processing memories Combating negative self-judgements 3.) Since they believe they are beyond redemption they need an equally forceful contradictory experience. 4.) There is no shortcut to healing. Stress the importance of community in the healing process.

Adaptive Disclosure Therapy (AD) Developed by Brett Litz and colleagues in 2007 1 RCT showed reductions in symptoms of PTSD symptoms 2nd RCT underway Eight Step CBT Group designed to help veterans/first responders process their possible mistakes. Veteran/First Responder also learn how to disclose in a safe environment w/o guilt or shame. Psychoeducation / share stories / write letters / confide in an internalized benevolent moral authority (or real moral authority) (n=44 Marines) A randomized controlled trial (or randomized control trial; RCT) is a type of scientific (often medical) experiment which aims to reduce bias when testing a new treatment. (1) stabilization and safety, (2) trauma processing, and (3) mourning, reconnection, and reintegration.

Impact of Killing (IOK) Developed by Shira Maguen PhD (VA San Francisco) One RCT Pilot Study Focuses on self-forgiveness, making amends, healing relationships, and moving forward Reevaluation of responsibility if appropriate (otherwise acceptance) Eight Phases Not meant as a stand alone, used in conjunction with other therapies Sounds like AA to me #1 Chopko et al., 2015 Listed in “The Role of Moral Suffering in Police Compassion Fatigue and PTSD: An Unexpected Topic Mistake in the line of duty resulting in the death of a colleague would be the most stressful. Of 34 potentially traumatic experiences rated by police officers, OIS rank #2 as most stressful. #1? Developed to be an Individual Therapy, not Group. Eight Phases 1.) Pre-Treatment Evaluation (Assessment) 2.) Common Responses to Killing Parts 1 & 2 (Emotions, Behaviors and Beliefs) 3.) Cognitive Behavior Therapy (CBT) Elements (CBT framework) 4.) Becoming Unstuck (Maladaptive killing cognitions, intro to acceptance) 5.) Acceptance and Moral Injury (role of betrayal in moral injury) 6.) Forgiveness Parts 1 & 2 (defining Forgiveness, barriers to self-forgiveness, forgiveness letters) 7.) Taking the next step (Forgiveness letter, making amends, connecting to others) 8.) Maintaining Gains (Healing as a Process) Uses plain talk. Use the word killing, not taking lives, or eliminating targets. Focuses on forgiveness. Interviews with participants later said “forgiveness” was the most challenging and the most rewarding part of the process.

Building Spiritual Strength Building Spiritual Strength is a spiritually-integrated model for treating PTSD/Moral Injury designed to reach veterans who will not access conventional mental health services. Dropout rates for BSS range from 6% to 14%.

Building Spiritual Strength (Group Therapy) Session 1: Orientation to group rules Session 2-3: Communication skills for talking with Higher Power Session 4: Theodicy (Why God permits evil) Session 5: Meditation and Prayer Session 6-7: Forgiveness Session 8: Consolidation of Gains

Questions? Sgt. Mike Hanafin Mhanafin@scottsdaleaz.gov Natalie Summit LPC; First Responder Specialist at The River Source Treatment Center in Gilbert, AZ Work 602-739-7119; natalie.summit@theriversource.org Personal 480-236-0781; changesat50@gmail.com “If only it were all so simple! If only there were evil people somewhere insidiously committing evil deeds, and it were necessary only to separate them from the rest of us and destroy them. But the line dividing good and evil cuts through the heart of every human being. And who is willing to destroy a piece of his own heart?” ― Aleksandr Solzhenitsyn, The Gulag Archipelago 1918–1956

Bibliography Brock, Rita Nakashima, Rev., Ph.D. and Lettini, Gabriella, Soul Repair, (Boston: Beacon Press2012)   Junger, Sebastian, Tribe, (New York, New York: Twelve, 2016);

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