Welcome everyone to our symposium. Thank you so much for coming out. Totally appreciate everyone's taking their time to listen about moral injury in the military. I'm here, Lieutenant Colonel Walt Soden from Tripler Army Medical Center. I'm the Director of Research for the Department of Behavioral Health there and I'm here with three of my colleagues, Chaplain Eric Reynolds, our Clinical Chaplain at Tripler and two of our esteemed residents in the Psychiatry Department. Captain Julia Schrader and Captain Natasha Schultz. Together we're going to give you a holistic and comprehensive view of how we think about, treat, diagnose symptoms and expressions related to moral injury in the military. Here's our disclaimer. So these are our opinions, not the opinions of any institution or government entity. This has been approved by Tripler and the research that we're going to present has been reviewed and approved by our Human Subjects Review Board and IRB and there are no conflicts of interest for any of us to disclose. Okay, I want to start today by a little thought experiment. I want you guys to think about something. So I want you to think about a gentleman named Captain Avery. He's been in the Army about eight years. He finds himself in Helmand Province in Afghanistan at about 2010 time frame. He's a company commander of about a hundred soldiers under his watch and in this day he's been assigned to set up a checkpoint at an intersection right outside of town with the mission to screen people coming in and out of the environment to make sure that they're safe and that they're supposed to be there. He issues what we call an operations order to his men. Within that operations order is what we call the rules of engagement meaning these are the things that need to happen and you need to do based on the situation and some of those rules of engagement are if a car approaches the intersection or what we call the blocking engagement, if they don't adhere to the signs that are 100 meters, 150 meters and 50 meters that say, you know, clearly you need to stop, you need to be prepared to be searched and questioned prior to being authorized access to this particular village. So there's three signs 50 meters apart all the way to 150 meters and then if the car continues or anybody continues past those three signs warning shots are fired and if they get within, you know, 20 meters of the post then you are authorized, not only authorized, you are, you know, meant to engage the target because then the intent might be hostile. So on this day a small vehicle approaches, doesn't adhere to the first sign, soldiers take notice, second sign still take notice, the speed is consistent, not the individuals in the car aren't changing their intent or their speed, gets past the third sign now the soldiers know what they need to do, gets closer, they fire warning shots, get on a bullhorn, start speaking in Arabic to the car, car continues, then the soldiers are left with no other solution than to engage the target and so they open fire on the vehicle as it approaches at a fast pace towards the checkpoint and they destroy the vehicle killing all the passengers in the vehicle. We do a, you know, battle damage assessment and an after-action review and find out that this was just a family of individuals that for some reason or whatever weren't paying attention and didn't adhere to the warnings, the several warnings and it's a normal family, just two adults, two small kids, all passed away and, you know, during the after-action review the soldiers are distraught, they're grieving, they're wondering why, asking all kinds of questions as to how this happened, but of particular interest is Captain Avery who, you know, a 30-year-old individual issued these orders to his soldiers and has a really hard time with it knowing that this tragedy occurred on his watch and his command and by his soldiers. So, you know, he seeks aid from the behavioral health providers there at the Fort Opry base, they render care, he's seen by the chaplaincy, he's still struggling, continues to struggle with this sequence of events and decisions he made, redeploys back to home station, the suffering and the symptoms or the expressions that he's experiencing get more and more critical and intense to the point where he has no choice, you know, to leave the army. He leaves the army and then still seeks care through the VA, through other agencies, nothing really works and ends up taking his own life. What do we call this? Do we call this post-traumatic stress? Do we call it depression? Do we call it something else? Some of us in the community are calling this moral injury which hasn't been officially diagnosed or described in the ESM. There's no real criteria that has been outlined. There is research and there is a growing movement that this is a very common kind of set of circumstances and follow-on reactions that service members experience, especially those that have served in a combat environment. And it's becoming more ubiquitous and frequent in our society. We're seeing now that it's expanded beyond the military and it's being documented in various fields to include health care, education, family environment. It's a real phenomenon that I think it's important for us to really get a handle of and start to think about how we can diagnose this and treat this and help these people who are suffering from what we call moral injury. So moral injury is, like I said, ill-defined. If you get into the literature, it's the wild west right now because there is no real parameters for how we structure this phenomenon. But this definition is probably the most utilized by scientists and practitioners today and it's from Litz et al. in 2009. And they define moral injury as psychological, a suite of psychological, biological, behavioral, social, and even spiritual factors that arise from someone experiencing or being exposed to what we call a potentially morally injurious event, meaning that they have witnessed or been exposed, thrust into something that violates their moral code or breaks their moral compass. And so this definition is what we'll use during this symposia as kind of a touch point as we move through the different talks and the different ideas that we're going to present today. So moral injury, like I said, it's ill-defined but I'm going to do my best having been exposed and kind of looked through the literature. This model presented by Litz is a good model and still a fair amount of people who are in this space studying it or treating it find this model useful. It just starts with the transgression and it's a subjective experience. All of our morals are different but you believe that you have committed or experienced or have been committed to you, some sort of transgression that violates your moral beliefs. And this causes some sort of cognitive dissonance or psychological dissonance where it's hard to square what you're experiencing or what your beliefs or behavior are at that time with what you believe is morally right. And then there's a process of both cognitive properties, emotions, behaviors that lead to a do loop where people who continue to experience these thoughts where behaviors that they've witnessed don't align with their moral values to an extent where it can cause functional impairment and be morbid with other ailments that we commonly see in our population like PTSD, depression, anxiety. I just listed out here on the left or on your right kind of how we look at moral injury right now in our community. And like I said a minute ago, this is beyond the military now. This is kind of a ubiquitous phenomenon that's becoming more and more prevalent throughout society. But it starts like PTSD with an event we call a potentially morally injurious event. The potentially is because it's not always going to be the same for everyone. Like I can see something and you could see the same thing. I could be affected by it where you couldn't based on my my DNA, my experience, my development, all kinds of things that work into that psychologically and socially. But we know that these PMEs usually fall into one of three categories. Acts of commission, meaning I've done something or I've seen something happen that would violate my moral code. Acts of omission, meaning I've I've seen something or done something that is failure to act, meaning that I could have stopped something or I could have not participated and I failed to do that. And then witnessing, experiencing, or learning about just immoral acts. Again, subjective experience of what's immoral or not. Now if you look through the literature, several things have been, you know, connected to this concept of moral injury. But, you know, trying to summarize it, moral injury is characterized by a certain set of moral emotions. Shame, guilt, disgust, anger, and remorse. So both self-condemning and other condemning emotions. A sense of betrayal is a huge part of this. Either you've betrayed yourself or someone has betrayed you or some group of people have betrayed you. Loss of meaning or having an existential conflict is another big part of it where your belief system is somewhat shook or shattered. And this is a characteristic of moral injury. And then a big one is the inability to forgive yourself or even going farther, self-sabotaging yourself, condemning yourself to the point where you may experience elevated suicide risk. And then just changes. Like with physical injury, when you break a leg or, you know, your arm, your physical, you know, body has changed and you have to go through some sort of healing process to reconfigure that limb or that body part. Same thing with this type of injury where you're, because of what you've did or what you may have experienced, your belief systems have been altered. Kind of like a physical bone would be altered if you broke it. And this involves not only your beliefs about the world, but also just your own personal identity or your self-concept. And then it seems to have an outsized effect on trust. Trust in yourself and trust in others. So one of the controversies, or for lack of a better term, in the literature is this, you know, is it PTSD? Is it not? How is it related? It's related to PTSD. However, we're finding that it's becoming more and more of like this Venn diagram describes where there is components that are overlapped with PTSD, but then there are components that do not share the same kind of constitution that PTSD does. As we know, to be very simplistic, PTSD is more fear-based and other things. And there's other symptoms that go with that that you don't see in moral injury and vice versa. Moral injury is like, like I said, those self-condemning emotions like shame, contempt, disgust, and even other condemning like anger. That's kind of a typology of moral injury. And you see behaviors that you would not see in PTSD. And then there's this middle group of things, for lack of a better term, that kind of describe both from depression, anxiety, insomnia, anger, and suicidality. So we're going to talk about moral injury in the military because that's what we care about. That's our day-to-day. We are all in the military. We service military service members from a mental health perspective. So like I said, we're going to talk about moral injury, but this is a bigger problem than just the military population. So what's the prevalence of moral injury? So moral injury has only been, or for the most part, only been studied from the perspective of the antecedent events or the eliciting events. So what we call, like I said, potentially morally injurious events. And so when I talk about prevalence, it's how prevalent is this experiencing these types of events for soldiers? So very limited data, you know, as far as prevalence studies, but there are a few that are of importance. They're also robust and reliable. So in 2017, WSCO and colleagues said that, you know, from the data of this nationally represented database, that about 41 percent, 42 percent of service combat veterans had reported some kind of potentially morally injurious event. And then a little later, a little more up-to-date, Magan and colleagues in 2020 looked at a national sample of post Vietnam, I mean post 9-11 veterans, and they bumped it up a little bit to about 55 percent. So that's the last kind of prevalent study in the U.S. military population. And again, that's with veterans, not with active duty service members. And then a more recent one in 2021, but it's with the Canadian Armed Forces, and this was with military personnel deployed to Afghanistan. So those that have seen combat, 65 percent. So now we're getting into like two-thirds, almost two-thirds of military personnel from this particular population have reported some sort of moral violation that they've experienced. And the other thing I have on this slide is how this is currently measured. This is the, I hate to say gold standard, but the standard of how moral injury has been represented in the scientific literature. And as you can see, this is just experiencing events. It doesn't get into expressions or what we might call symptoms, if this wasn't a DSM. It's only about those eliciting events. So why are military personnel more susceptible to moral injury? So I said that this has become a ubiquitous issue in society, but really we know that it affects service members and veterans a little more and a little more frequent, a little more intense. But why is that? Well, it's the context in which soldiers operate. It's inherently dangerous. It's high stress. It's bureaucratic and hierarchical. It's transient. It leads to a sense of uncertainty, doubt. You're exposed to things that most people aren't. And all this kind of forms a cauldron where people see and do things that aren't necessarily the right thing to do based on the context that they find themselves in. But you're left in these environments with not necessarily a good decision, bad decision, but several bad decisions and you're just trying to figure out what's the best of the bad decisions. And so this leads to, hey, I'm struggling and I've done something, I've seen something, something's happened to me that just doesn't jive with my moral kind of code. So the PMEs in the military, they've been kind of put into three buckets, and that's how we think of them. And we'll hear about these three different buckets throughout the presentation. So the first one is self-directed transgressive acts. These are, hey, I've done something. I shot something I shouldn't have shot. I had to negotiate and say some things that I wouldn't say normally. I did something. So that's the first bucket. And again, it's commissions and omissions. So it's not only that I do something, but I could have done something that I didn't do, which sometimes is more powerful than the actual acts of doing. And then other directed transgressive acts. This is witnessing harm caused by others. So people in your squad, they mishandled a prisoner or they extorted, you know, information in a moral way, or they failed to prevent harm. And then the last one is these betrayal-based. Because of the hierarchical nature of the military and the trust that soldiers have to put into their organization, their profession, the people around them, especially their leaders, a lot of times things don't happen the way soldiers believe they should, and this is an antecedent to moral injury, this sense of betrayal that you've been led astray, you're working for someone who is incompetent. When I say someone, not just an individual, but it could be the institution above you, or just someone told you or promised you something that just didn't pan out, and that could lead to moral injury. So why is this important right now? Well, it's important because it is beyond just the military. This is an issue of national defense. It's about the mental health of our best and brightest, people who have volunteered to serve their country. Every one of these individuals is eventually going to leave the military and become part of society. I'm assuming there's people in this audience that once wore this uniform that are now serving their country in a different capacity, like I will be in about a month. And then there are veteran organizations that have a huge say, or have a huge stake, in how our communities, our cities, our states, and our country are organized and ran. So this is an important issue, not just for us soldiers, but it's an important issue for society at large. And to do this, to address this, we have to attack it from, and I use that term attack just because it's in my vocabulary, but address this from different perspectives. We gotta look at it from a research perspective, we gotta look at it from a medical perspective. Because of what moral injury is, we have to incorporate the spiritual side. And that's critically important. Like a lot of things that we scientists or medical professionals, sometimes that component is something we push aside, or we know it's there, but it's not as important as others. But for this particular phenomenon, it's extra important to recognize the spiritual component intertwined in this. And then we have to look at this from a service member and a veteran perspective, because they're different populations. They're similar, and within, they're the same people, but there are different characteristics and different things that we need to pay attention to for these two separate populations. So together, we have to come together as a holistic community and think about this phenomenon and how we're going to address it. So our objectives today for this symposium is to give you some information that you can take away about the assessment of moral injury and how it manifests in military personnel. I'm gonna go through a psychometric analysis of some data that we use in a collection mechanism we use in the military, and a new scale that has been introduced to measure expressions of moral injury called the Expressions of Moral Injury Scale Military Version. Chaplain Reynolds is gonna talk about the role of spiritual guidance in treating service members experiencing symptoms of moral injury. And then our two residents are gonna give excellent presentations. First one by Captain Schrader, she's going to talk about what this looks like in the military. What are some examples, two case studies and how it's treated from her personal perspective. And then Captain Schultz is gonna come back and present some data that we've looked at about the transition, about soldiers hanging up the uniform and joining you all as civilians and what that looks like and how moral injury plays a role in this transition process. So here's the order. Each of us can get up about 15 minutes and then give you a different perspective. And at the end, I'll come back and try to wrap it up, take questions and get your all's input on how we can address this as a community, both researchers, doctors, therapists, chaplains, lay people, just what's the best way for us as a whole community to address this. But we're gonna start with measuring moral injury. So I said that it's kind of the wild west and if you think just thinking about this from a diagnostic and treatment perspective is wild westish, measuring it is even crazier because right now there is no kind of standard so people are introducing all kinds of scales and their thoughts and validation is sketchy and we know that there's a vital role of measurement in psychiatry that we don't talk as much as we probably should. It might be, and I know I'm a scientist so I'm a little biased, but it might be the most important thing we do when we're developing tools to assess, looking at how valid these assessment and treatment tools are, really understanding how they're working without putting the hard science of measurement to these instruments or to these materials or ideas. We really don't know what's going on with them and in this field, this kind of domain, the one injury, it's pretty wild. If you go into the literature, which I'm sure a lot of you have, you'll come across 10s, 20s, 30s versions of how do I measure moral injury and they all do something different. And so it's really important for us because it's so critical with our population that we need to get a handle on what are some valid tools. So to validate a tool, not to insult anybody's intelligence, but a quick review, there's these three things that we need to do. We need to look at its accuracy, how well does the tool measure the phenomenon that we think it's measuring, precision, how consistent does it measure what we think it's measuring, and then appropriateness, especially in a specialized context like the military. We need to make sure that the tools we're using are applicable to the specific population that we are interested in and care about. So in the military, we have a platform, a digital platform where any service member who comes into a behavioral health treatment facility, they fill out, or they're supposed to fill out, and that's a whole nother talk, but fill out the behavioral data portal. And this is a survey where service members, family members sit down on an iPad or a computer and they take your basic screening measures of depression, suicidality, anxiety, relationship satisfaction, demographics. It's a great tool. It's a great tool for researchers. I think clinicians might have a different story sometimes based on how long it takes to fill out or how it might get in the way of what you're really supposed to be doing, that's sitting with patients. But in theory, it's a great tool to be used for research, for validation, for diagnostics, for efficacy checks of treatment modalities, stuff like that. But we use it, and then we've been using it since the 2014-ish. And then a couple years ago, the military said we have these three different versions of this, and over the years, they've gotten a little crazy because the Air Force is doing one thing, the Navy's doing something else, and the Army's doing their thing. And so they said, we need to standardize this because we're moving to a model where we're not gonna be just Army, Navy, Air Force. We're gonna work under a separate organization called the Defense Health Agency, and we're gonna have to be able to offer standardized care and standardized measurements, standardized tools, and all that kind of stuff. So they mashed them all together, came up with one survey that all service members take, regardless of branch. And within that survey was embedded one of these scales of moral injury. And it was kind of a newer one at the time. Actually, it was a very new one at the time. It had, the article that kind of introduced it had just been published two years prior, so very scant validation data. But they include it nevertheless, and although it was an optional tool for physicians and therapists to use, it has been used to a good level of frequency. So I thought this was a good opportunity to see what is this tool, what does it look like, what's it doing, is it valid, is it reliable, in a very important population, and that's military clinical setting. So here's the measure. It's 17 items long. The goal was to measure expressions. So unlike the MIES that I showed you earlier, where it's antecedents or eliciting events, this was actual symptoms that have been related to moral injury in the literature. And it was measuring two different types of moral injury. One self-directed, and the other other-directed. So there is some, like I said, there has been some validation to it. It appears that when you look at the source material, that it was developed using rational, iterative, and a rigorous process, where they had experts go through it, they had different versions, a battery of questions that they weeded through and came up with the 17. It does show good internal consistency, reliability, and validity. The only problem here is that it hasn't been studied with active duty service members. There are a few small studies that they've tried, but nothing robust. And I couldn't find any literature in my review where they studied this in a clinical context. So in military treatment facilities with therapists and physicians treating those people that have come there for help. And so big hole that we needed to address, and I thought using this data was a good way to do it. So my question was pretty simple. Is this a psychometrically valid tool that we should be using in this context? I asked for, and through much consternation by the powers that be, they did eventually let me have a year's worth of data to go through and take a look at some of these psychometric properties. And then I just kind of in a very rudimentary way just wanted to look at the accuracy, precision, and appropriateness of this tool. So here's some descriptives. So a little over 3,000 patients. Demographics is what you'd expect from this population. Mostly male, a good breakdown of ethnicity. Good breakdown of people partnered with children. Across all the branches, mostly active duty. Years in service, we're getting a full kind of range of service members, young and experienced. And then as far as encounters, about a little over 25K. So on average, any patient that did take this tool got it about eight times throughout their treatment. One took it 91 times, which I thought was pretty interesting. Little bit of an outlier. So I'd start off by just looking at the appropriateness based on what the literature says. Does this measure capture and only capture the things that we'd want it to? And is it represented well? And then I want to look at the psychometric properties, basically reliability, validity tests. And then I wanted to look at how it's related or how we would think it should be related to other things like PTSD, depression, and so forth. So content validity, again, not to insult anybody, but it's basically just, hey, is this doing what, is it measuring the phenomenon that we're interested in? And does it represent the construct domain and nothing else? Part of the time what will happen is we'll measure too much. We'll have what's called concept creep, where you start to get into things that aren't part of that construct and you're measuring other things. So it's really important to just make sure that this instrument is measuring what it's supposed to and only what it's supposed to. So what is molar injury? So we talked about two important things, the actual kind of process model of moral injury, and then its relationship with PTSD. So these are two important things that needed to be aware of when we're evaluating this type of validity. So here are the items. And I went through it and I kind of highlighted some things. It does, in my opinion, cover most of what we'd expect in moral injury. I do see some omissions. The identity part is not as well represented as I would expect, or the self-concept, or the beliefs. I think that that part they could have done a little bit better, including that. But the other stuff, the emotions, the cognitions, some of the behaviors, well represented. So in my opinion, and I am just one person, it has some face validity, and then it looks like it's context applicable. Again, this is the military version of the scale. And so there is also a more general conceptualization of the measurement as well. So psychometrics, looked at construct validity. So do these 17 items have two underlying structures that they theoretically believe is how moral injury operates, the self-directed, the other directed? So using factor analysis to look at the validity of that claim, and then how well the data maps onto the theory. And then reliability, so not only do the items within those subscales cohere, but are they consistent across time? Are we seeing the same measurements taken at different time points, and with different people? So how do the items cluster together? So this is the theoretical. This is how they measured it, and this is how they report it, the original authors of the scale. And then people who have used it subsequently. They have nine items that are self-directed, and eight items that are other directed. So the first thing I did was call the exploratory factor analysis. I just looked at the data just kind of from a non-theoretical perspective, and just said, hey, how do these items cohere together? And for the most part, it matches the theory. There's this one item. I sometimes enjoy thinking about having revenge on persons who wronged me in the military. Now we know revenge is a really kind of nasty intent, emotion, whatever you want to call it. So it doesn't surprise me that this is split across the two, so it loaded, to use a term we use in research, it loaded onto both factors at a very low level. So that was the only item that I had questions of about. So the next thing I did is I did what's called a confirmatory factor analysis. So I wanted to see how the data fit the different theoretical and empirical conceptualizations of how I seen it or how the literature shows it. So I had these three different solutions. The theoretical solution with the two sets of items and how they've been written about by the originating authors. Then the empirical solution where I kept it in both of the components, and then I had a hybrid solution where I just dropped it all together. I said it's too confusing, it's gonna muddy, it's gonna cause noise, so I dropped it. You can see all three models fit the data well, but it's the hybrid solution that fits it better than the others. The CFI and TLI you can see is higher and then the SRMR is lower, which are good indications that this solution fits the data. So this is how I've used it going forward in trying to look at the validity of this scale in our population. Now just so you know, I have used the other two solutions and there's not much difference. So looking at predictive validity, I looked at concurrent, so cross-sectionally, how is it related? Then I looked at how the EMIS might predict different outcomes, and then incremental validity. When we're talking about functional impairment, how much variance does this account for above and beyond some of the other outcomes like depression, anxiety, and importantly, PTSD? So just quick stats, not to bore anybody with this stuff, but it is related to how you'd expect it. It's highly related to PTSD, both cross-sectionally and longitudinally, but it's not perfect overlap, so it's what you'd expect, highly correlated, but there's room for them having each construct having its own kind of characterization. And you can see that it's related at different degrees with these constructs that you'd expect from depression, anxiety, general distress, insomnia or sleep problems, and relationship satisfaction. Now there's other measures in the BHDP, but I just wanted to focus on these kind of basic ones that our clinicians use as screeners for service members. And then importantly, incremental validity. So it did account for an important amount of variance in everything but PTSD. In PTSD, it didn't seem to add too much to the story about what's influencing functional impairment. So again, it is something by itself, but it's highly related to PTSD to the point where when you put them both in a regression model, the moral injury one doesn't account for much variance. Future directions. So now that we have some evidence that this is a valid and useful tool, we're making the claim that it should be used more frequently by providers. But to do that, we have to test and think through how we integrate it in a smart way. And then eventually start to incorporate it into personalized treatment plans for veterans and service members. And then use it as a tool for both assessment and then monitoring treatment plan efficacy. And then I'm currently doing some further analysis looking at sensitivity, specificity, maybe develop a cutoff score system for it. And then looking at different treatment modalities and how this predicts the efficacy of those treatment modalities. So I'm gonna pass it on to Chaplain Reynolds and he's gonna get into some of the theology behind this. Good afternoon. I am Chaplain Reynolds. I am in the United States military. I may not look like it. I'm practicing my retired look. Some people get it. I wanna tell you a small story. It's not true, but a small story. Where we had this commander, a clinical researcher who after a long deployment decide that he's going to take a break and go on vacation. We call it leave in the military, but he's going on vacation. Wanna hike the Appalachian Trail. And so he packs all the necessary requirements like a good survivalist or a good soldier would do. He has his food, his water, his shelter. He also brings those things such as a small weapon and some bear repellent spray or some insect spray to kind of help doing this long trek along the trail as he get ready to clear his mind. And so while being in the military, his stance has changed several times and now he landed in a place where now he considered himself to be an atheist. And while walking this trail, he encounters a bear and he pulls out the weapon. He begins to fire at this bear who arose from hibernation. You know, the bears who arise from hibernation is hungry and determined to get that source of food. And he's running, firing this weapon. He pulls out the bear spray. Nothing seems to work. And he comes to this huge tree and he decides that he'll climb this tree. And while climbing this tree, he heard a voice and says, if you would call on me, I'll save you. And he thought, man, that's kind of illogical in my point of life right now because that seemed kind of like a hypocrite. If I call on you right now and ask you to save me, what would all this research and all these things that I've done in the world, what would that matter? So, but I tell you what, you can turn that bear into a Christian and I know that bear do the right thing. And the voice says, so be it. He wipes the sweat from his brow, looks down, the bear claps his paws together. He says, Lord, I thank you for this meal. Let it be nourishment to my body. Immoral injury. We recognize that. First, we have to recognize what are morals? Morals are a sanctioned set of rights and wrongs or a set of rules that are dictated by our groups, our families, our organizations to set some boundaries within us. That separates us from the other animal kingdom, right? Or the other part of the animal kingdom. It separates us, our moral, our conscious, not the only thing that separate us, but it is some of the things that help us, right? Because if that bear came into the room and ate someone, we would not call that bear immoral, right? But however, God forbid, if someone came in a room and started some trouble or pulled out a firearm, we would say that is highly immoral. Why? Because there's something innately divine or innately developed in us, whether we believe in God or not, that separates us from the animal kingdom that says there's some rights and wrongs, there's some things that we ought to do in the world. And so, the army recognizes 221 different religions. So yes, you can be a Jedi in the military, okay? Just in case you didn't know that, all right? But you can be a Jedi. And so, it's 221 different religion. And so, what the army began to say was those who maybe come from a different aspect of life, who may consider themselves amoral, who has an indifference between right and wrong, or maybe some of those people who maybe lived a life that was kind of immoral and thought about there's no right and wrong. There's organizations such as the military or such as your profession that where you may have to take an oath to something higher and bigger than you to live in a standard or in a set of boundaries that set some rules and regulations on the inside to live an ethical or to do an ethical and moral job. And so, the army has these 221. But yet, the army went on further and says, if these people do not, this is what we will also put into place. The army says there are several characteristics that the soldier must live up to. That soldier must be loyal. He must have a sense of duty, respect, selfless service, honor, integrity, and personal courage. Why? Because it wanna build on to some moral congruency and to help that person live a moral, ethical life inside the military and while conducting military duties. And so, we too have those things outside. And so, it didn't start, moral injury did not start in the military. There is a genesis. Sorry, I'm the one forgetting to turn the slides. I'm supposed to do that. But there is a genesis to moral injury. It just did not start 20 plus years ago. It started way back in. We have historical records. We have sacred records. For as in Genesis chapter four, God comes to Cain because Abel is now dead and says, where's that brother? And he says, am I my brother's keeper? And so, he marks Cain with this marking that says, hey, wherever you go, people gonna recognize you. Why? Now, there's a set of rules and regulations that have been put on not only to Cain, but also on society that is not the way we ought to live. So, ever since man has begun to kill one another through whatever means necessary to kill one another, there has been some people that come along and say, how do we justify doing acts that society says is wrong? And so, Homer wrote in his Iliad about Euripides and 4 BC, and Euripides says that, what can I do, O? Where can I hide? What hole can I go deep enough to get away? Because I'm soaked in blood and guilt. St. Augustine in the fourth century wrote something because he was trying to help those soldiers recognize that when soldiers come in from battle, that they was torn. And so, he wrote this to help soldiers who want to be loyal, not only to Caesar, but also to God. And so, he came up with the just war concept. Thomas Aquinas began to expand on what the just war concept says, because the just war concept, just to narrow it all down, says that if you do it for your country, then you are legally bound. But Thomas Aquinas came and says, let's add a little bit more to that. And there's three things that he wrote into this to justify or to expand on the just war concept. He says, it not only should be authorized by an authorized body, which we do have Congress and Senate who authorizes us to go into war, but it also must have a just cause to it. The just cause of what? The just cause of we're good and they're evil, or getting rid of evil out of the world. So, this is another concept that was added. And it also must have the right intentions. It must be justice behind it. Can you see how this applies to even the soldier today and how this has really been working its way down through the century and becoming more and more? President Obama stood and gave a speech when he received his Nobel Peace Prize, and he talked about the just war concept and how the soldiers should conduct themselves. And so, Jonathan Shay came around in the 1990s, and he says, there's a moral injury when all these moral things are broken that the person now is experiencing a moral breaking or a injury, a soul injury, or a wound to the heart that they can no longer function the same. And so, as chaplains, we're taught, clinician chaplains, we're taught this graph here. And it's broken down into three areas. It talks about the personal. It talks about the organization. It talks about God. And it says, from the self, is how that person perceives themselves now after a moral injury. And for the organization, it says that this organization now I trust because anybody who would take an oath to join that organization means that I inherently now trust that organization. And so, and then when it comes to God, it said, okay, God, I trust you because you created this whole world and you made us sacred. What is that sacredness that I'm created in, that man is created in the imago Dei, that we was knitted together? That just, that's only in my theological construct that we hold to that. But I'm only telling you that since I am a Christian. But many religions hold to this religious tenet that sacred beings are knitted together or created by a sacred God. And so, that is the self part of it. But when the moral injury happens, the person begins to think, I did something terrible. Oh, I'm bad. Oh, look at me, woe is me. But he also began to think about the organization, how the organization has screwed him over, how the organization has broken this trust because you can only be betrayed by something you trust, right? We can be sabotaged and stabbed in the back by enemy. We recognize the enemy goes to do that, but betrayal comes from those organization or people around us that we trust. And so, the soldier begins to think, now I've been screwed by this organization. And he also begins to think, God, you're not real. God, you are horrible, irrational. How can these irrational, horrible things begin to happen if you were real? And the symptoms that comes from an immoral injury or the consequences that comes from a moral injury is guilt and shame, but they're also some social withdrawals that begin to happen. But through the organization, anger and cynicism and a lack of trust begin to happen within the organization. But with God, there's a lack of faith, a loss of faith, a redevelopment of a whole new person. With God, it says that you no longer exist to me anymore because all these things begin to happen. And when the moral code is broken, again, Dr. Soden says, acts of commission, act of mission and betrayal. I'm gonna name three things that all of us maybe have experienced at least some more injury that you may not even thought of. In 2007, that little square rectangle that you have in your hand was invent, well, the cell phone was already invented. However, the smartphone came along and then that smartphone was able to video. So what happened at 9-11 and what did it make you feel like? What happened on May 25th, 2020 when everyone saw the George Floyd incident, riots and everything? 9-11 caused a mass recruitment through all the military branches. It went through the roof. What happened October the 7th, 2023? We still feeling the effects of that today. All of us, we're not immune because we're in the military. We're all going through it. Why? Because the definition says, if I witnessed something that happened to me that can cause me a moral injury, now what do I do with that? And so all these things, and we may feel like my government has betrayed me, organizations have betrayed me. And so we act out because morals cause us to act out or morals cause us to act in a specific, in certain ways, right? Because as a psychology forensic person who creates profile, they look at the behavior and they can track back to the morals. Well, likewise, morals also dictates how a person act. And so when you come to a moral injury, you're left with these emotions of, there's some regret, some shame and some guilt. Now what I do with this? And so many people began to act out. And so that person now is a new person, a new being. And so whether he used to view religion or whether he used to view his community, even to his family, that person may not view those tenets the same. And so there's going in the military, you come in as X and you may leave as Y. I have to now reestablish it. Now I have to really question what is good versus evil? What is right versus wrong? What is all this? There is a wound going on inside of me. And so though the head is logically in the brain, we think logically, but that's also attached to the heart where we get our meaning from. And when these things are out of congruent with one another, there comes a questioning of a person purpose. Who am I? What am I to do now? What's new in my life? And so we begin to see society, we begin to see family as someone totally different. I've been on six deployments and I remember coming home and not recognizing my children, but at the same time, I began to treat my children and my spouse as soldiers instead of my family. Why? Because I've been changed. I saw so much that happened to me. And so that changed my perspective. And so I began to see them in a totally different light. I had these negative emotions of guilt and shame and anger, but could not express them. Yes, sir. But there's a disconnect between religion and psychology. And that disconnect is the science versus the spiritual. The professional psychologist versus the uneducated layman. And this is why, as a chaplain corps, we are bringing up our chaplain corps to have more than just a master's degree, but to go on and get your doctorates and other professional documents. Why? Because we are viewed as uneducated beings, people who live in the religions, in the fiction world, who live in this place where science can't measure God, where God cannot be put in a test tube. And so for you religious folk, God, for you religious folk, there can be some judgmental and some critical things going on. But we also look at it through that lens of that religion is escapism, is a way to avoid reality. And that's the disconnect where we train to bring together both the religion and the psychology together. And so how do we treat the moral injury from a religious point of view? Talk about the whole forgiveness. Forgiveness of self, forgiveness of those who perpetrated, forgiveness of the organizations. We began to, as chaplains, we have organization where we began to take Vietnam POWs back to Vietnam and let them sit down with their captors. That was also done during World War II. And let them begin to sit down and let healing begin to take place because we recognize that forgiveness is a real construct. But also we want to journey with them in finding a new community. If you no longer X, then if you are Y, then let us help you find a place where you truly belong and fit into this new place. And so we also began to facilitate grieving, the lament process. There's a grieving process goes on with moral injury. And lastly, we certainly reconstruct the whole new faith. If you want to keep your faith, then how do we reconstruct that to make it fit who you are as a person? Because you are sacred and you are precious and valued. Thank you. Next, we'll turn it over to Dr. Julia Schrader and she'll go over our clinical portion. All right, everyone. I'm Dr. Julia Schrader. I am a third year resident at Tripler Arnie Medical Center. And today I will be speaking to you about military moral injury from a clinical perspective. So my goals today are to look at the risk factors that predispose to moral injury. I'll review two cases of my, that I have in my panel of moral injury. We're gonna go over understanding moral injury as a distinct syndrome, a set of symptoms, and we're gonna overview some of the treatment options and therapeutic targets for moral injury. All right, so before jumping into the risk factors, reminding that moral injury is a violation of one's moral code, right? There are many different ways. And something I wanna put in your mind just at the very beginning is, at least from my standpoint, and this is my opinion, I've seen more of betrayal, specifically institutional, maybe some leadership betrayal with some of the younger soldiers, younger sailors, Air Force, whoever we see. We're not necessarily deploying them as much anymore. And when we are, it's different than it used to be. And so I do have a case of each to show you, one where there is some more of that commission omission, as well as one of an institutional betrayal. And so with that, I can let you read some of the risk factors, and just keep a couple of things in mind. A lot of them make sense, right? You're gonna deploy multiple times, you're going to have exposure to violence, you are more likely to have a moral injury. But something else that's interesting is, just by being junior enlisted, you're one of our kind of younger, we would call like E1234. You have a lot of risk factors here for moral injury. You're young, you're lower rank, you might have lower education if you're coming in at 18 years old, right? Lower income, you can look it up online. As you go up in ranks, you get higher pay. And then interestingly, just another key thing for us, in Hawaii, we're pretty isolated. So a lot of people have low support. They're far away from families, friends. So we see a lot of these risk factors in the people that we're seeing. All right, and so here's some articles. Again, I've got these up for a couple reasons. No, I'm not in the Navy. This is an Army uniform, you're correct. But at Tripler, we treat all branches. The other reason was, again, I wanted to kind of illustrate what could an institutional betrayal look like? What could set up for that? And then third, I'm highlighting my own families. Experience within moral image, or with moral injury. So this first one, the Lincoln Strike Group, that was my husband's first deployment. He deployed when COVID hit, and he lucked out. He was on a supply ship, so he got one port call before everything closed down. But everyone else, nothing. And so they were able to float around for what was it, over 200 days. They set a record, it's great, right? Whilst Lincoln was deployed that first time for my husband's first one, I'm sorry. Oh, I mixed it up. I lied. This is not my husband's deployment. He was on the Eisenhower. The Lincoln set a deployment, my friend was on that one. The Truman, when my husband's ship on the Eisenhower was deployed, that's when COVID hit. That's when they floated around. The Truman was coming home. But they were not allowed to come home. They had to float up and down the coast. I don't remember how long. It was at least a couple of weeks. It may have been up to a couple of months, because what if COVID hits? We had the Roosevelt over in Guam that got a little bit crippled because they had a COVID outbreak. And so they were not allowed to return home after a very long extended deployment until the Nimitz deployed. And so while the Truman was floating up and down the shore, the Eisenhower was not allowed to return home. The Truman was floating up and down the shore. The Eisenhower had just deployed. And they're sitting there thinking, no port calls. Am I gonna be extended? Am I even gonna be allowed to come home? Setting up for a pretty perfect morally injurious case. So this was his second deployment. I have the right ship this time. But pay attention to the wording here, right? It's a bit different. And this was from the Navy Times website. So here we say, this is the second double pump, what they call deployment, in many years. It'll send it into another exhausted period, or extended period of repairs. Furthermore, the move raises questions about why the deployment is necessary at all, when the military is supposed to be focusing on the readiness and moving away from running its forces ragged. And so here's some more anonymous feedback. I got these from Reddit. There's one for Navy. Apologies if there's cursing. It's the military way. But you might see some common themes to this. So I'll kind of go, every five seconds or so, give you some time to read. Some more about leadership, quality of life, kind of similar, respect, why are they making us do this, we've served. Similar to the article, we've been going at this high speed for so long, why is this still happening? What are we doing? To share the love, going back to my branch, the army. Weeding out cancerous people in leadership roles, leadership, betrayal, leadership again, leadership, and not just leadership but an institution that they're saying perpetuates some bad leadership. The goal here is not to bash the military, we do some great things, we do some not great things. I'm just trying to build up and show you as to what I'm seeing clinically, some of the things that my patients are telling me. So moving on to my first case, this is a 26-year-old male, he's active duty army enlisted, he's a staff sergeant. He had a deployment to Afghanistan. So his past psychiatric history is significant for major depressive disorder, he's been treated on and off at our clinic for about two years by two other providers, and he's been largely non-compliant with medications and appointments. He'll come in, kind of fall apart, maybe go to one or two more appointments and then not show up. Show up months later in a worse state than he was before, continue, continue, continue. He had no suicide attempts, no hospitalizations, no substance use treatment. Substance use, the only thing significant was really the alcohol. And when I first started seeing him, it was less than monthly, but before he had had a history of drinking six days a week or so, maybe about one to two drinks a day, sometimes six drinks in every sitting, or in a sitting in a week. It's gotten worse, now he's drinking a whole bottle of vodka a night to fall asleep. So medical history, not very contributory, just obstructive sleep apnea, he does use his CPAP. And so no significant psychiatric family history. So social history, so he has a strained relationship with both his father and his sister, and that's because he came home from deployment and tried to tell them about his experience, and they said, you signed up for this, and he cut him off after that. He had a stressful job or has one, he's Intel, I'll go a little bit more into that in a minute here. And he had a recent breakup with his pregnant girlfriend, who has since given birth to their child due to self-isolating behaviors lashing out at her. So he's got a couple of things that have come up through our sessions together, but his primary trauma was he's working as a drone operator gathering intelligence, giving it to friendly Afghani forces. And so he put together a report with his officer in charge, his captain, and they sent it up saying, hey, this base is going to get overrun, warn your people. And no one listened. The base got overrun and everyone was killed. These are Afghani soldiers. And so, again, Intel, Intel, Intel, what does he have to do? He has to review the footage, not just of what happened here, but all the time. But with this one, he got to see the evidence of the people he tried to save being tortured, dismembered, beheaded, killed. And it's not an isolated incident, right? He's doing this all the time, so he has a lot of exposures. That's his primary trauma, but he also gets stuck up on, I send in drones and they kill people. I kill people. I'm a bad person. So what are his symptoms? He's depressed. He's got anhedonia, anxiety, irritability, difficulty falling and staying asleep, self-detachment, self-isolation, stopped hanging out with his friends, doesn't talk to his family anymore. The interpersonal difficulties I mentioned, arguments with his girlfriend lashing out, no ex-girlfriend. He gets intrusive memories. He has feelings of guilt and grief. He blames himself for what happened. He questions his morality. How can I be a good person if I've killed people? How can I be a good person if I think people deserve to die? And then passive suicidality. So he denied flashbacks, hyper-arousal, hyper-vigilance. And at the time I wrote this, he denied vivid dreams, but he has since developed nightmares. So what is his moral injury? So we'll say, I've used the word perpetration, but so kind of an omission. I could have done more to save these people, but there is a commission base as well. I sent in the drone. I killed these people. And then a betrayal. Why didn't the leadership listen to me? I knew this was going to happen. I did all I could, but at the same time, I could have done more. So he has very heavy guilt and grief. He doesn't think he's a good person. He thinks he deserves to suffer. So moving on to case two. This is a 32-year-old male. He's an active duty Army officer. He's a captain, my rank, 03. He had a deployment history to Kuwait. His past psychiatric history is notable for adjustment disorder with anxiety and depressed mood. He's also been kind of in that like one to two years being seen in the clinic. No significant changes in that diagnosis during that time. So he had one psychiatric hospitalization for suicidal ideation with Pan, and he completed an intensive outpatient program. No suicide attempts, no substance use treatment, no significant substance use. So when I inherited him, he was on bupropion, acetalepam, prazosin, and hydroxazine. He also had sleep apnea being treated with a CPAP. His family history was significant for possible depressive disorder in his mother. Socially, he has a history of physical abuse from the father, pretty bad abuse, too, strangled, chased out of the house with a gun, witnessed domestic violence between his parents. He attended college. He was on the ROTC scholarship. He was very motivated to serve in the U.S. Army, and he had put in 10 years in the military. And so he also, one thing that was significant for him, worked a very high-stress job as a general's aide, and that is what led to his suicidality and his hospitalization. So what were his symptoms? Kind of similar to my other patient. Depressed mood, hopelessness, self-isolation, anhedonia, immotivation, difficulty falling and staying asleep, nightmares, suicidality, feelings of worthlessness, guilt, anxiety, and lack of purpose. And these are some of his quotes. I wish I never joined the Army. I wish my career were different. I wasted my life. I feel like a failure. I feel like the Army has failed me. All right. So this, I believe, was more of a case of that institutional betrayal. He was belittled, degraded by superior staff, given assignments he didn't want, felt misled and dismissed about those assignments, felt lied to. I lost my trust in the Army. The military is not what I thought it would be. So going into the syndrome, right, there's no agreed-upon definition, but there's some similarities among the literature, and we saw these in some of my patients. Intrusive thoughts, the shame, guilt, disgust are big. Anger and irritability, self-isolation, feelings of betrayal, loss of trust, religious struggles, loss of faith, loss of meaning and existential crisis, questioning my morality, self-harm and suicide. We already went over kind of the similarities between PTSD and moral injury and the differences. Again, PTSD, fear, anxiety-based moral injury, shame and guilt, they overlap and are often co-occurring. So what are some associated mental health outcomes with moral injury? PTSD is the strongest. Makes sense. A lot of the criteria on A, trauma, can be morally injurious in itself. So we also get depression, anxiety, substance use, interpersonal difficulties, sleep disturbance, suicidality. So how do we treat it? In the literature, there's no one specific or best treatment. It depends on the patient, is my advice, right? So there's things that it's like, oh, yes, these things do show some evidence, or maybe it doesn't. But all of the therapies listed at the bottom there have been studied in the literature and it's kind of hit or miss. That's why I say, target what the patient wants. What's bothering them most? Is it the guilt or the shame, the loss of trust, maybe some maladaptive thinking patterns, reclaiming your values, your self-identity, self-forgiveness, acceptance? And again, so things like cognitive behavioral therapy, cognitive processing therapy, prolonged exposure therapy, eye movement, desensitization and reprocessing therapy, adaptive disclosure. From a specifically medication standpoint, there were no specific guidelines. It'll probably be something like treating the symptoms. Are they also depressed? Are they also anxious? Are they having nightmares? Are they having substance use problems? Do they also have PTSD? Treat those things as you would appropriately. So what did I choose for my patients in the case outcome? Case one, we tried a couple of different things. I finally have gotten him coming into therapy for the past four months regularly. We've tried some CBT, CPT, trying to cognitively think through things. We hit a wall. I deserve to suffer. We tried doing some ACT, reclaiming values. I've got values, but I still deserve to suffer. We've tried some EMDR. We've tried written exposure therapy. I still deserve to suffer. So that's what we're working on with him. He's unfortunately not made a lot of progress. Case two, we did a lot of the same, kind of the cognitive processing, cognitive behavioral therapy, challenging some maladaptive thinking patterns, focusing on some self-forgiveness and acceptance. How could you have known that this is how things would turn out? The guilt, shame, loss of trust. And we did some EMDR for him as well. And he did a lot better. He had a couple points in GAD-7 and PHQ-9 improvement, and then his PCL-5 dropped by 20 points. He's doing great. He's out of the Army now, and he's looking forward to moving on with the next chapter of his life. So in conclusion, moral injury appears to be a distinct syndrome that is different from PTSD. They have distinct symptoms like loss of trust, religious struggles, loss of faith, loss of meaning, existential crisis, questioning your own morality. There's no one specific or best treatment. I recommend targeting specific symptoms such as guilt, trust, self-identity, self-forgiveness, acceptance, as well as any co-occurring conditions that might be happening. And then another thing I didn't put on there is, again, my opinion, but I've been seeing as we're deploying less and less to some of these more austere environments, you might experience more combat. I'm seeing more and more people come in saying more of an institutional leadership betrayal rather than commission omission. And that concludes my segment. Thank you. All right. So we'll try to wrap things up here with looking at the military to civilian transition specifically. My objectives for this portion of the symposium is to review a study as well as the results of said study, discuss some potential factors that may have led to affecting that outcome, and explore ways that we can help support our transitioning service members. I'm not going to spend too much time talking about the reason for the study because I think that's been talked about ad nauseum already, but we know that there's high prevalence of moral injury in the military. We know through the literature that there appears to be a link between PTSD and moral injury, and those studies typically tend to look at it after transition has completed. So really our goal was to see, okay, what's happening during transition? Is there a change as a service member is exiting the military, and is there a role that moral injury might play in that as well? So what we ended up doing is for individuals that had indicated that they would be exiting the service, they were sent an email where they were being recruited to the survey, and if they accepted, they were given a survey six months prior to the date that they were supposed to exit the service, as well as six months after they had exited. The survey consisted of validated tools that have been used to measure PTSD, so like the PTSD checklist military version, we used PHQ-9, GAD-7, we utilized the Deployment Risk and Resiliency Inventory, and then we also utilized the Morally Injurious Events Scale, as Colonel Sonin spoke about earlier. And then we also included demographics that have been historically shown to influence military mental health, so to include things like age, gender, race, time in service, and their rank. And so as the survey was constructed in that way, after retrieving the data, what we used was a hierarchical multiple regression analysis across three different models to see what might be accounting for variance in this change in symptoms. Our first model specifically just looked at the demographics to see if in the population itself if there was anything that lent itself to that variance. The second model then included combat exposure, and then finally the third model looked at potentially morally injurious events. And through analytic progression, we were able to see how these were interacting between each other as well as the effects on mental health, specifically focusing on symptoms of PTSD, anxiety, and depression during transition. And so here's just a quick breakdown of the demographics, very similar to what Colonel Sonin had shown you earlier in some of his work, as this is part of a bigger study. But we did have 624 service members that completed the pre- and post-survey. And as you can see, majority were white, male, enlisted. There was a range in age from 1 to 4, or range in the years served from 1 to 40, and their typical time was around 12 years, which shows us that we were getting a good sample of people both at the beginning of their career as well as those nearing or retiring. And that's played out, too, in the chart showing our age breakdown, where the majority were 22 to 30 years of age, then a large portion being 8 to 21, and then 41 to 50. And so if you're thinking about, OK, what are the service members that are making up these groups? Well, that's individuals that have maybe done a couple tours, and then they're considering, OK, do I get out? Do I stay in? We also have ones that may have just done one contract or didn't really adjust to the military culture and got out. And then, of course, retirement is the other large thing to consider. So what were our main findings? What we found was that betrayal-related and PMIE, potentially moral injurious events, where personal morals were violated by a trusted other, that was found to have a statistically significant effect on PTSD symptoms and anxiety, but it did not seem to have an effect on depression. And interesting enough, self-directed and other-directed PMIE weren't seen to have any increase in PTSD symptoms. Other-directed did have an effect on anxiety, but again, none of them had any effect on increasing depression symptoms in that transition process. And so here is just the table laying out the data, and what's emboldened is the statistically significant findings. So again, showing the betrayal-based effects on PTSD and anxiety and the other-directed PMIEs for anxiety. This also validates what we've kind of already seen in the literature, that connection between combat exposure and PTSD symptoms, as that was again replicated here. So to just kind of talk about some of the questions and ideas that came up looking at this data, as these members are transitioning, some of the ideas were, well, as members are getting out of the service, well, do they even know how to effectively engage with resources? Could that might be contributing in some way that they are having increase in symptoms because they don't really have, don't know how to get that support once they do make that change. Also to consider that transitioning out of the surface is inherently very stressful. You're often looking at a complete change in identity, a move, the support networks that you have formed, you know, those are going to change as you move away from friends and people that you've known forever. So there's a lot of change, financial differences, it's stressful. And so another aspect is do they feel that they have people that they can talk to about these things or that they will be accepted or do they feel like there's maybe a taboo that people won't really understand them and that this is just their burden to bear ad nauseum. Again, we've kind of already talked about this point so I won't really belabor it, but how are those roles of the unique environment and experiences that military members experience affecting this as well, being in the military, having that hierarchy structure. And I also was thinking along the lines of, okay, so how do we use these tools clinically or would we be able to implement them so that we could identify these individuals prior to transition as maybe a target for therapy and being able to potentially get them into treatment before they transition. Because of importance, these individuals in this survey, they were just getting out of the service, none of them, or I won't say none of them, but it wasn't tracked whether they were receiving behavioral health care or not or if they had prior diagnosis, they were just getting out of the surface. And lastly, in future studies might we would be able to focus on those betrayal related events opposed to others because as Captain Schrader spoke about earlier, you know, research is being done, there's nothing that's really stuck so far, but maybe if we're able to target the specific events, that might tell us more. So limitations of this study, well there is risk of attrition bias. We did have like a retention rate about 41%, but that was pretty good when we're considering that this included active duty members. And when we're thinking about that, well, who all kept up with it? Are these the individuals that transitioned successfully and kind of had that capacity to follow up or, you know, were the individuals that struggled even more unable to follow up or did they follow up? It's hard to know based on this. Also the time period that we looked at, we looked at six months prior and post because that was the easiest way for us to get sure data on people exiting the service. But for people that are, you know, retiring or have a good idea that they're getting out, they can go ahead and interact with our transition assistance program as early as a year to two years beforehand. So we might have missed some of that change that was already occurring. And to follow that on, you know, the literature shows that in our veterans that the risk of suicide peaks around one year after transition, so we may have not measured far enough out. We're still gathering data, but based on what we had so far, there may be more changes that are shown. And last point I already mentioned is we don't know who was treated or had a diagnosis prior to this. And so personally what I have seen, just some of my tidbits, was service members they tend to wait until the very last minute to seek care. They're about to retire, about to exit, they say, hey I have this issue, I'm getting out in three months, can you fix me? Yeah, pretty fun to work with. Also again, the unique military experiences. I have had individuals, you know, say I can't talk to my wife about this, I can't talk to my family about this, you know, who am I going to turn to? I have to get this fixed before I leave because I just don't know how I'm going to cope afterwards. And much like Captain Schrader spoke about, a lot of disillusionment and feeling betrayed by the organization overall, that they just like don't matter and that they've kind of suffered for nothing. And another aspect is sometimes I have had individuals that feel really overwhelmed by all the resources. They don't quite know which ones are going to be most effective for them and it's kind of puts them off and they don't really engage with care until the last minute and adds a lot of stress to the process too. And also not all of our service members have commands that can allow them to take extra time to make sure that they are doing what they need to do to take care of themselves to transition. Some have to work up to the very end under high intense situations. So just to kind of wrap things up, what are some of the resources that we can help with transition? Well a big one is the VA and you can go to the website that I've listed there. They have plenty of resources to include case managers, help with finding careers, housing, what-have-you, treatment for PTSD, really anything you can need you can find it through there. Just to note too though that this can vary based on location to location so it is important to reach out to your VA specifically. And another aspect is for those that work with active duty members to make sure that you're getting them engaged with the transition assistance program as soon as possible and helping make sure they stay on track with that. And perhaps one of the biggest things that we can do as providers is as they transition make sure that we're setting them up to have that follow-up so that there isn't a drop-off in care and that they are able to transition and continue to engage if they need to. And lastly again really important, make connections with your local VA. They're going to know what resources are available and be able to help you out a lot in that regard so very important point. And lastly also don't forget that there are plenty of free apps out there that we can help give to our veterans and active duty members to interact with while they're going through this process as well. So I'm going to end my part there and hand it back over so thank you. All right so to wrap up we got a couple minutes left. What we did today is we kind of gave you a holistic picture of moral injury in the military. We went through some data looking at the BHDP and some psychometric properties of a scale that we're using to measure expressions of moral injury. You got a wonderful theological perspective from Chaplain Reynolds. Thank You Chaplain Reynolds. That was amazing. The talk by Captain Schrader on like case studies and the actual clinical you know what we're seeing and the application of treating these expressions. That was an excellent talk. Thank you so much for doing that. And then we ended up looking at the transition. So a big part of this is we leaving the uniform transitioning to civilian status and what is what is moral injury look like and affect that process. And Captain Schultz beautifully went through a study that we're running about that exact topic and so excellent work Captain Schultz. This is a call to action. So leave here, take what you learned, and apply it when you're treating veterans, when you're interacting with service members, or when you're thinking about hey I have someone who's military connected. It could be a family member. How does these concepts related to moral injury affect or influence my diagnostic, my treatment plans, and so forth. And then finally keep this conversation going. There's plenty of resources out there. Explore the literature from a scientific perspective, but go beyond that. You know that there is interdisciplinary research. As you can see we are doing research as a combined team here. I'm a research psychologist, we have psychiatrists, we're the chaplaincy. So work together because the different angles can you can cover some gaps that you may not see in your own purview. Share insights within your network. So leave here and share what you learned with other psychiatrists and other behavioral health providers on what can we do to address and expand our knowledge about moral injury. And then you know advocate for policy development, having this codified, figuring out how pushing for people to look at the overlap between PTSD, a little more detailed work. Advocate for more research into this very important concept. I have a couple minutes for questions for any of the panel members, but I do want to say thanks because without the partnership between our civilian colleagues we can't treat military personnel or veterans. So thank you for attending. Yes ma'am. Hi, Haley Gilmore from LICOS. Is this on? Great. You mentioned that moral injury is not in the DSM. I don't think it's in the ICD either and I was just curious if the panel thought that there was value to it being added and what you might do to proceed with that. I'll defer to the clinicians. I have an opinion but I'll let them talk. I think that more and more like getting, it might be helpful to have it, yes. Getting it defined and seeing it because already in the literature it's a distinct set of symptoms and that could help with more research into like what could be effective treatments for it to be able to better and take care of what is a very big problem within our military. We have what 65% of people that are being exposed to morally injurious events. It would be almost negligent not to take this seriously to have it put into one of those two at the very least. I would add just one thing like there's there's tools out there like I presented some validation work on a scale like use those tools even if you're not super comfortable with it or you know never done it before. Use them with your veterans or with your military connected patients and see what it's telling you because I think the more data we can get and the more conversations we can have between scientists and practitioners we'll be able to build a case for it being included in those in the DSM and so forth. Right now I don't think we have the case because the empirical knowledge is scant and so that's how we could go because it may not we may not we may find out that it is just something to do with PTSD and we can we can we can handle it that way but you know I have some intuitions that it's not and it probably is a good idea to run forth with these hypotheses that say hey this is something different and maybe it should be included. Yeah to add on one more thing with that is that literature as well is starting to look at not just veterans they're looking at health care workers, reporters, like foreign aid workers. It's not just in the military and so I think that as more and more comes out I would expect that it'll snowball on itself and that it might find itself into one of those two categories. Ma'am. Hello my name is Lisa Cohen I'm from Mount Sinai New York. I'm struck by the description of moral injury how central the issue of self-loathing is and I thought clinically this would be an excellent setup for groups because groups have been incredibly effective with people who experience stigma such as AA. So getting veterans or possibly active-duty soldiers together to talk about their experiences. There may be some resistance at first but you guys are the experts could figure out how to structure it. I think it might be more effective actually than individual. That's an excellent point. What do you guys think? Yeah absolutely. I think that with for example my first case that's something that I've been trying to encourage for him and so at some point it's a bit complicated. We're doing what we call medical boards so I can't send him to certain places because he needs to be present for appointments but once that's done that's something that I'm very much looking into and what me and then one of my clinical supervisors is saying it's like he thinks he's alone. He needs to know he's not alone and so getting him into that group where he can be like how other people have experienced it. What have they done that might help? I think would be absolutely essential for him so absolutely. Exactly. That's a great great point. As Chaplain Clinicians we at our hospital we just developed a group group called Shattered Bonds and where we are going through talking about these moral injuries and allowing them to come together so we have included our vet side as well our VA side to bring in these individuals begin to talk about it as a group and again to share things that you normally wouldn't share on the outside. Thank you. Thank you so much for your work and your passion for this subject. It's very important. My name is Seth. I'm a fourth year medical student. I matched at MGH for my psychiatry residency. I'm a research affiliate with the Harvard Human Flourishing Program and we just finished a proposal to the DSM for a Z code for moral injury and we heard back positively a month ago. That's great. That it could be added and so Z codes are non-pathological coding structures. They're non-billable. They're not used as much but the hope is that it doesn't pathologize moral injury but that it can be an add-on code to like PTSD or an adjustment disorder. That's similar like burnout right? Yeah like bereavement would be so uncomplicated bereavement was an example of a Z code that's commonly used. So my question is from a clinical perspective we don't even know would this be utilized and would it help? Yeah that that's question one and then question two when it comes to treatment Brett Litz has done a lot of work on adaptive disclosure therapy. He recently came out with findings from a trial a multi-center VA trial testing adaptive disclosure was which orients forgiveness and spiritual techniques into CBT and and I was wondering what your thoughts are on on those trials in that. It's young right? It's young like you're right that's that's probably it's on the edge that we're at right now with Litz's work and so again this is you know we can trace back the concept of moral injury to Shay's work in 94 and then the work by Magan and Litz you know in 2009. So this is very an immature body of literature and we're right now at the very you know edge of starting to do trials and look at different modalities for treatment and so the answer your question is super promising but we need more evidence you know so I think we're headed in the right direction but I want more clinicians and other that you know you see the same authors names on the papers right there's this group of maybe five ten people that are doing all the work we need more psychiatrists more psychologists more researchers to get involved in this body work but excellent point appreciate it and good work on getting that Z code. I would use your Z code hundred percent. Hi this is so important and I think it's just so great to see research being done because it's through research that we get resources to then apply it right sure I'm interested in the clinical application I'm a recent graduate working for the past six months in an outpatient community VA clinic and it's I I feel like I see that but I don't know how to address that because either I have young veterans that just got out of service and they don't know how to navigate it they don't know who to trust or how to talk about it or I have like veterans that have been seeing the clinic for a long time and they kind of got used to what they feel and what they do and if I ask something they it's hard to talk about that it's hard to get that and then I'm like I have a 20 minutes to talk to them during psychiatrists like how can we get there you know I think you're right I hear this from the physicians I work with I've talked to them about this I think using this language using these these ideas in your your sessions and in your work I mean it it creates a language that the veteran or the service member can talk around like using the idea moral injury talking them about it yeah I understand it's not in the DSM and stuff but still it's it's a thing like we have enough of a body of literature to say that this is something that is an actual construct and a phenomenon that we need to utilize both from a scientific perspective but in a practical perspective as well and I think more importantly to Captain Schrader's point I did a review of the literature about how moral injury is becoming a bigger phenomenon than just the military I mean it is now studied at a twofold rate in other contexts in the military so we're seeing in health care your colleagues are suffering from moral injury doctors and and and providers are suffering from moral injury same type of same type of expressions because of triage decisions you know think resources being constrained poor leadership that type of stuff so this this is we're at the beginning of something that is going to eventually get into the DSM and eventually going to be used by so use the language, talk to them, because veterans and service members recognize that. I mean, so, just take this and build on it, so I appreciate it. Thank you. Sir. Thanks very much for your presentation. One of the things that I think is really interesting, and it comes up with the Z code, comes down to this place about what becomes billable and what becomes a medicalized model of different injuries. So, your point around the leadership component, the carrier is getting extended, right? That is mission, needs of the Navy, all the things that essentially leadership has to be able to help negotiate and navigate. And I think one of the things that I see, I'm Navy doc, so I see this all the time, where we don't actually invest in our leadership to help be able to explain and project out the why so much of what we do. At the end of the day, like I work in flight medicine mostly, right? People are doing things all the time that become very problematic. Z code become very helpful, because then you have a reason to at least talk with somebody about things. One part that I think is really important for us is that, you know, when we get into a model, and I think DHA is a moral injury for most of us, from the standpoint that at the end of the day, the ability to be able to support our service people is not the medicalized model that would be incorporated by Sinai or any of the other other kind of groups that are out there. So I talk a lot about peer support, engagement across like areas where folks can at least have space to talk about these things. I think that actually gives a lot of leadership perspective to the junior folks to be able to say, hey, as we move forward, we're going to continue to deal with this stuff. We're not deploying in the same types of way. And I think like just being out in the world, right, and the Navy does something very different from the garrison mentality that's even present in the Army. It doesn't have to be Fallujah. It doesn't have to be what's happening in like Afghanistan or anything else to sort of say, hey, you're being asked to do a task, even if it's supporting what's going on in the Red Sea right now where people have a lot of conflict about it, but can you understand why we are doing this locally for each other to be able to get home and to be able to move forward? The Z codes, I think, help support that, but I think we also have to be able to ask to have more resources that don't have to fall into a medicalized place, because the other component, right, that you're dealing with, and I was going to say in the case presentations you're coming forward with, like there's probably other diagnostic realities from a personality disorder component or other things that are true about that person's life story that also become important. And so where is it that we can sort of suss these things out? I think trying to find ways to recognize it is important, but as you know, right, as we find a place where almost, right, two-thirds or more of the folks that are in the system feel that sort of oppressive nature of what's going on, we have to be able to talk about the fact that leadership, the explanation of the why, and then also recognizing the burden that we share as a shared component of like the sacrifice that's inherent that only will become true, and that's a part of translating this idea over into the civilian counterparts to sort of say that people that have done these work or have sacrificed in this way might not have a ready degree of being able to process it, so I really love the component around doing group work in that space. I think it's really important and useful. You know, for you all as you're finishing up residency, thinking about like where a non-medicalized component of your treatment also becomes relevant for mission readiness I think is critically important, so thank you again. Awesome. Thank you. Sure. Thanks for that. Sir. Hi, everyone. Thank you for a great presentation. My name is Dr. Nicely. I work at the Psychosocial Rehabilitation Recovery Center at the Bay Pines, Florida VA Hospital, and we certainly see a lot of moral injury. Going back to the definition you provided of moral injury that a soldier's expectations do not line up with their actual experience sometimes, I think a lot of soldiers start very idealistic. They have a lot of idealism, and they have maybe a lot of naivete. The question is do you think training early in a soldier's career about what they, you know, explicitly what they might experience while they're serving would help reduce the rates of moral injury? Yeah, interesting. So I have a, this is just a pet theory, but I think there's this thing I call the trove of cynicism where we come in, we come in, enlist, or get a commission in the military, and we're very idealistic. We're motivated, I want to serve, I want to jump out of airplanes, I want to do the right thing, I want to lead soldiers, all that stuff. And then you hit reality, and it's not the movies, and it's not what your uncle told you, and it's not all that stuff. It's a grind, and it's hard, and it's ambiguous, and you get disappointed a lot. And so about that time when we officers, so regular Army officers, you have to spend four years as a lieutenant, then you become a captain, a little different in the medical field. About the end of that four years, and you put on captain's bars, or for the residents here, when they get out in the Army about four or five years after their residency, that cynicism, that gap starts to, you start to hit that. And that's what you're talking about. You're talking about expectations hitting hard against reality. And that, in my opinion, is a lot of the pain. That creates a lot of the pain. I'm actually doing a study with a similar method that Captain Schultz presented, where we're looking at expectations explicitly. What is the role of expectations in transition stress for exiting soldiers? So you are, I think, and this is just my opinion, you're right on something. I think expectations really are going to tell us something about what's going on here, especially when we're talking about betrayal. And also, I want to say, sir, too, what the Chaplain Corps has began to do in this area is that, unlike the other branches for the Army, we're putting chaplains down to the lowest echelons. So we're beginning to now, to expose them. This is why we, last two years, we have reconstructed a whole Chaplain Corps, just not to be such, so much to focus on the spiritual, though that is very important, but also on the moral aspects. And so, while doing that, we now begin to teach moral injury to our Lord's ones, and to begin to work up these things. So we're trying to get chaplains down to the lowest echelons possible, so that they can have this exposure and be ready when the real scenarios do happen. Awesome. Yes. Thank you. Thank you. All right, no more. The softballs are over. Here comes the cutter across the plate. This is one of our alumni from our residency program. Yes, I've been outed, but also Army. My biggest question was, you know, we've all seen it in the Army, and I'm not sure on the civilian side, or I'm sure at the VA. The 2021 Afghanistan withdrawal, it's probably the single most common recent, like widespread cultural level of moral injury I've seen. It's almost every soldier I've had that deployed to Afghanistan had some degree of moral injury from the sense that they were betrayed by the government, that everything was for nothing. All the people that I lost, and nothing came of it. The other guys won. Yeah. And I'm curious, and you mentioned George Floyd as well, chaplain. I'm curious if there's anything in the literature or anything that's been studied as far as like population level, like kind of widespread moral injury from a single event like that. Yeah, that's a great point. I remember when we were talking about the pullout of Afghanistan, and two of my colleagues and I, we tried our darndest to study this in real time, because we knew that this was what was going to happen. We knew that soldiers were not going to take this well. It was a loss, and it's not going to make us feel good, and it was probably going to result in some real psychological mental health issues. We couldn't get the study off the ground because of military bureaucracy. But, which is my own personal moral injury, just joking. But I think you're going to see studies coming out, because I have my ear to the kind of railroad tracks. People did study this phenomenon through COVID, and they studied it through the Afghan pullout, and they've studied in other places. So I would not be surprised as good papers start working their way through the publication process, in the next couple of years, you'll start to see something published around real time kind of natural experiments and how moral injury unfolds when these things occur. But you're absolutely right, Josh. That moment where we pulled out of Afghanistan really left a mark, and I know you're seeing it in your practice, and all of us who are wearing this uniform, we feel it, and we know our buddies that have felt it, to the point where they've exited the service, and they're super bitter, and they still have these feelings, and we're a couple years away from it. So excellent point. Thank you. Yeah. Hi. First, thank you for your service. I'm a data analyst at the VA, one that's associated with the National Center for PTSD, and we work a lot, primarily with folks with PTSD, modeling PTSD and suicidality, but we've also been looking into chaplaincy care, which is a little difficult in our cohort. It's a little older. I know they've tried to change some things around. One question I had was, there was talk about risk factors, and I know risk factors for development of PTSD is pretty well established, longitudinally, like which comes first, but I wasn't sure if that was the same for moral injury, because it's kind of new, but things like, are younger service members more likely to develop moral injury, or are the ones that remain in the service who tend to be younger, because the older folks leave if they encounter moral injury, so it's like a chicken or the egg. No, no, that's a great question. I was wondering if either there are any papers you could point to regarding those risk factors, or if that's, if there's- Yeah, so there's a couple, and you're probably aware of these, there's a couple of recent review articles. There was a whole issue of the Journal of Traumatic Stress in 2019 dedicated to this, and it was reviewed, and there's a couple of literature reviews, meta-analysis and stuff, so I would start there, and then, because you're a good researcher, do a citation chain and figure out what's been done since then, but that's where you would start. I've done, I've written a paper that just got published where I looked at belief, so there's a construct in psychology called moral identity, so we have an individual difference around how we identify with morals, and I find that those that are, have a stronger moral identity, meaning that their moral self is more central and core to their sense of self, that those people, the connection between PMIEs and symptoms related to PTSD are stronger and more robust, and that's real important in the military, because we're all values-based. From the minute you walk into the Army, it's character, it's leadership, it's values, and so we're trained and developed to have a central, core, moral identity, but that is a risk factor. Having that is a risk factor, and so that work is starting to come out, like, more definitive ideas around what is risk factors. I don't know, I don't want to pop off and tell you that it's younger guys, because that's kind of the default answer. I think it's more complex than that, I really do, and so I would start with the review and that special issue of the Journal of Traumatic Stress, and then move forward from there, and you'll probably see more mature research. Yeah, yeah. You guys got anything to add? Anything? I'm Jeanine, I work with the VA in Canada, and I don't know if you're facing this, or if you have any ideas. I'm really interested in the transition from service to civilian life, and I'm running into a lot of veterans who left in a really bitter state, like you were saying, after the pullout of Afghanistan or whatever, but what I'm running into is people who became injured on duty, who are then basically ostracized in their units, and treated like they're collateral damage or something, they're damaged goods. The Canadian military has done something sort of lip service, which is to have, like, departing with dignity, but apparently it's not actually happening, because there isn't a cultural support for it, and I'm wondering if you experience the same thing, or if you have any ideas, because that feels like a preventable thing, to me, to prevent a lot of disability, if they can actually still be valued and moved on in a positive way, instead of this whole get rid of the garbage kind of attitude, I don't know. What do you guys think? We certainly see that. I've had many patients going through medical boards, being retired out for an injury that they have, and a couple where their primary concern is, is, like, I'm being ostracized. I'm useless. They even tell me to my face, like, I have nothing to offer. Go print things, you know. One thing we have in conjunction with our hospital is a soldier recovery unit, but the idea is that they get injured, they come back. Sometimes people get sent there, and it does feel like it's to rot until they're out, and so I don't know, I don't have as much experience within, like, having a system like that to depart with dignity. Sometimes they're just so relieved to be out that they're a little bit less bitter by the time it's time to go, but that's just been my personal experience. I know there's some more experienced military psychiatrists in the room who might know more. There's definitely some experience in the room, and speaking of, so this is our boss. I actually have more of a comment. So I'm Will Pitts. I'm the chair for the Department of Baby Health at Tripler, and I'm also one of those people that get choked up at moments like this, so bear with me. I'm also going to mention to you that he's retiring. A comment, not a question. He's retiring. He's gone terminally. He didn't have to shave. He didn't have to wear his uniform, but he showed up to support his team. He is leaving the Army with a—we gave him one final poke in the eye on the way out, so he could have been bitter, but he didn't. He showed up today to support us, and today will be his last public appearance in uniform after 30 years, so I wanted to thank you. Oh, thank you, sir. Yeah, I appreciate that. Thank you so much. Yeah. It's the last time I'm wearing it. I appreciate it. Thank you. I'm blushing. I don't take this thing very well, so thank you. Speaking of thank you, I want to thank all of you for coming. This is super special to do this, my last kind of event, and I want to really thank these three. These are professionals that I talked into doing this, and so thank you guys for doing this. Wonderful symposium, and thank you to you all. Hope you enjoy the rest of your conference. Yeah, go ahead. Can I give her—Ma'am, one of the things that we're also beginning to do as well at the Triple Hospital, I reintroduced what they call the Honor Walk, such as when we have a veteran or whether they retire honorably. We don't even go through that, but what we do is recognize them in their service if they pass away in this dignified point of view, whether the family is watching or not, and give them a final salute. We heard about Honor Walk when they give organs, but however, we have Hispanics when they do pass away. What we're really trying to do as a chaplain corps is bring this value back because our core competencies is that we care for the wounded, we nurture the living, and we honor the fallen, and so we sometimes see these wounds as the physical wounds, but we miss the spiritual wounds, and so we're trying to really bring this into full fruition that there are some physical and spiritual wounds as well, and so when they leave, they need to leave just as with value. We come in the military with value. They check us over, and therefore, when they leave, they should leave with some value, knowing that they served honorably and with dignity, and so we try to bring that sacredness back to that aspect. Thank you. Enjoy the rest of your conference.

moral injury

military

PTSD

Lieutenant Colonel Walt Soden

Chaplain Eric Reynolds

Captain Julia Schrader

Captain Natasha Schultz

clinical perspectives

theological insights

Afghanistan

civilian casualties

emotional distress

treatment options

cognitive therapies

spiritual care