Good afternoon, and welcome to this session on Rationale for Incorporating Moral Injury into the Religious or Spiritual Problems Z-Code. My name is John Petit. I'm a psychiatrist at Brigham and Women's Hospital in Boston and Harvard Medical School, and I'd like to introduce our presenters. Jennifer Worthen, who was on the program, was not able to make it, and she's being replaced by Richard Cowden, who's a psychology research scientist at the Human Flourishing Program at Harvard. He'll be followed by Francis Liu, who's the Luke and Grace Kim Endowed Professor in Cultural Psychiatry Emeritus at UC Davis, followed by Seth Mattson, who is graduating from Baylor College of Medicine and an incoming PG-1 psychiatry resident at MGH McLean. We'll have them all present continuously and then have plenty of time for discussion. Our objectives are to define moral injury and differentiate it from PTSD, to describe how moral injury affects religious and spiritual lives of patients, and to recognize the importance of including moral injury as part of the Religious and Spiritual Problems Z-Code. Participants will recognize the significance of categorizing moral injury as part of the Z-Code and its implications for clinical care. We'll start with a revised definition and clinical implications of moral injury. Dr. Liu will talk about the impact of moral injury on religious and spiritual beliefs, and Seth will talk about the rationale for inclusion of moral problems in the Religious and Spiritual Problems Z-Code and some of the implications for clinical practice. As I said, we'll leave plenty of time for Q&A and discussion. So I'll turn it over now to Richard. Good afternoon, everyone. It's a pleasure to be with you all. As John mentioned, Jennifer Wortham could be here. She played a pivotal role in some of the working group engagements that we've been doing at the Human Flourishing Program on moral injury, and then also an important role in kind of coordinating the effort to revise the Z-Code that Seth and others will talk about later. So I'm going to talk briefly, sort of give an overview, background information on existing literature on moral injury, talk through briefly our working group sort of process at the Human Flourishing Program towards refining how we might define and conceptualize moral injury, and then briefly sort of distinguish it from PTSD. So the existing literature on moral injury has really proliferated in the last few decades, but it has much richer historical roots. And one example of that is the concept of miasma that the ancient Greeks used, referring to moral defilement or pollution, often resulting from unjust killing, but applicable to any transgression of moral values. And there's many anecdotal examples, descriptions throughout history of people having experiences that we might describe as moral injury or something closely related. And then the contemporary literature on moral injury emerged and developed from a few different strands. One is sort of moral distress literature focused on nursing, that's sort of Andrew Jameton's work in the 80s. And then more recently, early descriptions of moral injury emerged for veterans, and Jonathan Shade did a lot of that early work in the late, in the 90s and early 2000s. And then building on that was Brett Litz and his colleagues who provided sort of the foundational empirical advances in this area of moral injury. And Brett Litz and his colleagues have played an important role since then as well in kind of building this evidence further. This sort of early work really focused on conceptualizing moral injury as involving an act of transgression, either perpetrated, witnessed, or experienced as an act of betrayal. That act of transgression violates deeply held assumptions and beliefs about right and wrong or personal goodness. As you can imagine, almost two decades later, the scope of application of concepts related to moral injury has continued to expand, and now we have numerous conceptualizations and assessments concerning moral injury that have been proposed. One recent review identified at least 17 different conceptualizations and corresponding definitions of moral injury that have been put forward. And an example of assessments, a more recent review identified about 22 distinct measures of moral injury and related concepts just for military populations alone. As you might expect, there's lots of commonality amongst these different conceptualizations, but there's also some points of distinctions. And so one of our goals at the Human Flourishing Program is to synthesize evidence related to different kinds of concepts, topics related to human flourishing, broadly speaking. And so bearing in mind the risk of kind of undertaking an effort to refine conceptualization and definitions in terms of further fragmentation of literature, we thought it would be useful to go through a process of trying to synthesize existing definitions into a kind of coherent definition that we might propose, and then also work towards integrating some gaps that we identified into how we might define moral injury. So with those sort of two points in mind, we undertook a process. Over several years, we put together a working group involving different scholars, practitioners from different disciplines ranging from psychology, psychiatry, philosophy, bioethics, sociology, public health, internal and external to the program, and I think Seth will expand on this a little bit. But we worked through several years to eventually coming up to a revised definition that I'll share with you momentarily. But the sort of more core goals of that process were to expand the definition to be more inclusive of moral injury that might arise from the experience of being a victim. And then we also attempted to conceptualize moral injury in relation to moral distress. Also trying to conceptualize different aspects of severity and duration as a spectrum. And then as a supplement or secondary step, we worked towards developing assessments that can cover not only witness or victim experiences, but also, well sorry, not only perpetrator and witness experiences, but also victims. And that can apply across multiple contexts, military and non-military. But as I mentioned, this work in terms of conceptualization and measurement really just builds on what's already been done, tries to bring coherence to it, and is mostly consistent with prior work. So it's not a replacement of what's already been done, it's an attempt to synthesize. And perhaps more importantly or relevant to today is that lots of this work informed the DSM-Z code proposal that others will discuss in more detail momentarily. So up there is the working definition of moral injury that we put forward. Moral injury is defined as persistent distress that arises from a personal experience that disrupts or threatens A, one's sense of the goodness of oneself, of others, of institutions, or of what are understood to be higher powers, or B, one's beliefs or intuitions about right and wrong, or good and evil. And so as you can see, this definition is focused on the moral content of the experience rather than any particular symptoms. The phrasing is in terms of the distress, which allows for a range of possible symptoms to be co-present. And then inherent in the definition is that it requires a causal link to be present between the transgression or the experience and the threat to moral integrity, and allows for an experience arising from perpetrating or failing to prevent a transgression or from witnessing or from being a victim. So it's quite broad in scope. It also allows for both recent experiences and also experiences from the past that might be coming up in the present. It does not require the transgression to be from trusted individuals when we're speaking of victims, and allows for non-transgressive experiences, such as natural disasters. This sort of conceptual clarity we feel is important. One of the reasons for this is that it's helpful to distinguish moral injury from PTSD. And I'll just briefly cover some points along these lines, but conceptually we can distinguish the two along at least three lines. PTSD ordinarily involves a persistent re-experiencing of the traumatic event, whereas moral injury may or may not involve such. PTSD also requires avoidance of the trauma-related stimuli, following the trauma, whereas moral injury may or may not involve that. And then moral injury must always involve some action or experience concerning moral action or worth, and that may not be the case with PTSD. And then we can also look to sort of the empirical literature regarding treatments to perhaps look for some distinctions as well. So as one example, prolonged exposure therapy, which is often used for PTSD, may or may not be helpful for moral injury if guilt or shame or betrayal are not adequately addressed. And then adaptive disclosure therapy, spiritual approaches, or forgiveness interventions might be more effective for moral injury than for PTSD. These distinctions, we make these distinctions keeping in mind that there's going to be lots of cases where PTSD and moral injury will be co-present, or there might be a particular sort of temporal order between them where one causes the other and vice versa. So it might, in many cases, be difficult to actually distinguish these two, and hence the need for this kind of conceptual clarity around moral injury. Okay, I think I'll hand it over to Dr. Liu now. Well, very nice of all of you to be here, and I'm going to kind of give the connecting point to the DSM process, which Seth will continue to focus specifically on the proposal. So let me go over this broad timeline, if you will. In DSM-IV, which is now, what, 30 years ago, it's hard to believe, the category of religious or spiritual problem, which is abbreviated RSP, was added to the section entitled Other Conditions That May Be a Focus of Clinical Attention, or the V codes. And also there was an outline for cultural formulation, which was added in Appendix I, the ninth appendix. Then in 2013, in the DSM-V, the RSP was retained unchanged, and it has stayed unchanged. And I'll show you that in just a moment. The outline for cultural formulation was revised. The outline for cultural formulation is a series of five questions or areas of what are cultural issues. And the workgroup on culture and diagnosis, headed by Roberto Luis Fernandez, and I was part of that workgroup, felt it would be important to have a method or a way to help clinicians gather the information for the outline for cultural formulation. So for the DSM-V, the cultural formulation interview was devised of 16 questions to help gather that information. So in the DSM, in section three in the back, there is a core patient version, 16 questions, and an informant version of 17 questions. But in addition to that, there are 12 supplementary modules for deeper dives in specific areas. And so one of the supplementary modules was on religion, spirituality, and moral traditions. So in that supplementary module, that idea of religion, spirituality, and moral traditions was established there. And there are 19 questions covering these different topic areas. So for the DSM-V-TR that came out two years ago, again, the religious-spiritual problem was retained unchanged. The V codes were renamed Z codes to align with ICD-10. The introduction to this section was revised, and I'll show that to you in a moment. And the outline for cultural formulation was revised, but the CFI and the supplementary modules were retained unchanged. So this is the definition of religious or spiritual problem, and I and David Lukoff and Robert Turner made the original proposal back to the DSM-IV steering committee for this proposal, which was accepted. And this is, as you can see, a category of distressing experiences involving religion or spirituality. And this is in the section in DSM-IV, and these are selected parts of that introduction. As you can see, these are problems or conditions that may be a focus of clinical attention or may affect the diagnosis, course, prognosis, or treatment of disorders. But they're not mental disorders. That's very, very important. The conditions in this section are not mental disorders but are meant to help alert clinicians to clinical issues that may need to be dealt with. So in our proposal, we felt that it was important to improve diagnostic assessment by having, you know, this religious or spiritual problem category and to help with the issue of misdiagnosis and to help with treatment, because we would pay attention to these issues and encourage training and research in this area. Skipping ahead now to the TR, the latest version, what's in yellow here was added. As you can see, it was V codes to Z codes. But then also the reasons why we would want to put this in the diagnosis, I think this is very significant here, as you can see, is that if it plays, if this problem plays a role in the initiation or exacerbation of a mental disorder, or if it constitutes a problem that should be considered in the overall management plan. So I think that that kind of raises the stakes for why we should pay attention to this. This is not some trivial matter. But you know, it's really important that we pay attention to this. Okay. So turn it over to Seth now. »» I'll be discussing the overview of the Z code proposal and then discussing some implications for clinical care that we hope for. I also want to note, I'm going to dedicate this project to my mother. She passed away on Mother's Day of last year, right when I started writing this. So yeah, dedicating it to her. She was a dedicated physician and a mother of five. So thank you. To start, we'll have a case. Sarah is a 28-year-old nurse who has been working in the ICU of a busy urban hospital for the past three years. Recently, she has been experiencing overwhelming feelings of exhaustion, despair, and spiritual distress related to her work. Sarah recounts a particularly difficult shift where she had to care for a young patient with terminal cancer whose family was unable to visit due to hospital visitation restrictions imposed during the COVID pandemic. Despite her best efforts to provide compassionate care, Sarah felt helpless and distraught witnessing the patient's suffering and isolation. She found herself disillusioned by the conflict between her personal motivations, on one hand, for entering the field, and her current situation. She feels betrayed by the lack of support from hospital administration, as well as guilt for the role she feels she played in contributing to her patient's suffering. Over time, Sarah has noticed a decline in her motivation and energy levels. She struggles to sleep and finds herself becoming increasingly irritable and emotionally detached from her patients and colleagues, which is uncharacteristic for her usual empathic nature. So questions to consider in this case. Diagnostically, did she experience a traumatic stressor captured by PTSD, burnout, perhaps, or moral injury? In formulating treatment, how would this case be approached in current models of therapy for PTSD? And what about for treating burnout? And what would be missing under these current models? And lastly, how does understanding moral injury facilitate improved treatment in this case? And as I outline this proposal, our hope is that cases such as these will be captured and treated in a more holistic way. As a timeline, Richard mentioned some of the initial workings by a working group at the Harvard Human Flourishing Program. This began back in fall of 2021, where the program partnered with the Duke Center for Theology, Spirituality, and Health, forming the Moral Injury Project to work towards a consensus definition of moral injury and advanced moral injury as a disorder in the DSM. The following year, the Human Flourishing Program hosted a moral injury retreat with over 150 researchers and clinicians to advance this definition using the Delphi method and to review potential DSM criteria. And the definition that Richard presented is the fruit of that consensus definition effort. In the winter of 2022, the program formed a panel of experts to identify a best path for submission to the DSM committee. At this point, Dr. Petit, as well as myself, Dr. Liu, and Dr. Koenig, and others were consulted. And at this point, there was also a bit of a pivot. Up until this point, it was thought that perhaps moral injury could be included as a disorder. However, after a review of the literature combined with an understanding of what it takes to get a disorder in the DSM, most recently prolonged grief disorder was added in 2021, which was the result of 10 years of back and forth between research groups at Penn and at Columbia and the DSM committee. There were a lot of back and forth, hundreds of pages of research to get that approved. And with a look at the moral injury literature, the literature just isn't there yet when it comes to validating moral injury as a construct separate from other forms of traumatic stress. And when it comes to validation, this is very specific data on prognostic factors, response to treatment, biological markers, predictive and predisposing factors. And the literature is not yet in its infancy, but it's still growing for moral injury. So from this point, Dr. Liu and his experience with Z codes and being able to capture moral injury potential as a non-pathological entity that still affects clinical care, we decided to pivot to a Z code proposal. After about six months of writing, we submitted our proposal to the DSM committee. This culminated in a 58-page document with 10 literature reviews and over 200 references. In November, we received feedback from the DSM steering committee, overall positive, but they had follow-up questions regarding the risk of pathologizing, quote, moral problems and the final definition itself. In January, the committee proposed a few more final revisions and very pleased to announce about a month ago, we heard back with preliminary approval from the DSM steering committee and pending final approval by the assembly and board, potentially in the fall of 2024. And for context, how exactly is the DSM updated? This is a screenshot of the APA DSM submission portal for a type 7 DSM proposal, which is a Z code, either update or addition. And these are the different requirements. I'll be outlining some of the definitions and rationale as well as the prevalence of moral problems and moral injury reliability and the clinical utility of this construct. By now, you may be asking, okay, what was the proposal? And so we, to the Z code 62.89, we propose an expansion to religious, spiritual or moral problem. And underlined, you'll see the addition in the subheading. Moral problems include experiences such as moral injury and moral distress that disrupt one's understanding of right and wrong or sense of goodness of oneself, others or institutions. Improving and demonstrating the prevalence of moral injury. A little bit of history is important. Moral injury was first studied in military and veteran populations. However, the strains of the COVID pandemic heightened our awareness of the multiple factors leading to burnout. And as Wendy Dean says, if burnout is a destination and there are multiple routes to get there, moral injury is the unchecked highway. And the populations that moral injury has been studied in has since expanded beyond healthcare professionals as well. And this list grows every month. Moral injury is also found comorbid with many other disorders most commonly studied in relationship to PTSD. Also anxiety, depression, increased suicidal ideation and behavior. This has been noted independent of PTSD severity. Substance use disorders, burnout, as well as impulsive behaviors. And another thing that needs to be proven is can this construct be reliably measured in multiple populations? And there's multiple measures for moral distress that we included in our reviews, as well as moral injury. Some of them validated, some of them not, but they've been proven to be consistent in multiple populations. And now you may be asking, if moral injury is severe enough to where it increases suicidality apart from PTSD, why not include it as a separate Z code? And it's a good question. It's one that we discussed internally as a team as well as some back and forth with the DSM committee. Potentially a moral dissonance category or a moral dissonance problem category. And there's some benefits to a separate category. It provides more specificity, not conflating it with religious or spiritual problems. But going back to the data, we thought it was extremely important to highlight the connection between religious and spiritual distress and moral injury. And some of that I'm gonna be outlining here. So conceptually, moral injury is a value-laden existential construct regardless of underlying religious and spiritual worldview. Okay, so what does that actually mean? And does the data support that? And so this study by Ames and Currier, gonna unpack. Donna Ames, she was a recently retired VA psychiatrist out at UCLA. She did a study studying moral injury as well as religiosity and suicidality in a group of 570 active duty military as well as veterans. And what they found as predicted was that moral injury is strongly and independently associated with risk factors for suicide. But also that religiosity does not mediate or moderate this relationship. And so what this means is as they asked individuals how important religion or spirituality is in their life, which is measured by asking about the time spent in religious practice communally and independently as well as money spent and these other questions, they found that the more religious and spiritual individuals and the less, regardless of what they reported, the suicidality effects were the same. And so the religiosity, again, there was no causal link between religiosity and suicidality and then it didn't have any moderating effect as well. So we cited this to connect the two. And Joseph Currier and his group, different group, same year in 2019 published Moral Injury and Spiritual Struggles in Military Veterans. And they did an interesting study. They measured the importance of religious and spirituality pre-military and then post-military in two samples. One sample of 300 veterans and the other was of 600, so about 1,000 patients total. And then they also asked about different religious and spiritual struggles, divine struggles, struggles with morality, meaning, doubt. And then they subdivided this into self-moral injury. So this is moral injury that's perpetrated or witnessed or other moral injury, which is an event that's experienced, an act of betrayal. And they did some factor analysis and they found there's three distinct subpopulations. A non-distress group, a psychological moral injury group, and a spiritual moral injury group. And so, self-explanatory here, but the non-distress group does not report distress in these spiritual and religious categories, divine, doubt, interpersonal, moral, or meaning categories. But they also don't have any moral injury to report. Now, the psychological moral injury group in comparison to the spiritual moral injury group, you'll notice that they did not score as high in these spiritual and religious categories, but in the moral injury categories, they still were experiencing symptoms that were causing distress. And so, bringing those two studies together, it suggests that one, moral injury is a construct that is not isolated to those who are religious and spiritual, but this existential injury can happen to anyone. And two, that if you go back to this study, there's the individuals that were in this psychological moral injury group, they still had moral injury, however, they expressed it in terms that were not religious or spiritual. And so, by connecting religious and spiritual and moral problems as a broad umbrella category, again, it's not specific, but what it says is that it's the same core injury and the injury will end up manifesting in accordance with that person's worldview. It may be in religious and spiritual terms, but it may not, but by connecting them, it's recognizing that the injury, the existential injury is still the same. And then it aligns with the current cultural formulation interview, as Dr. Liu pointed out, with the supplementary module five and the appendix of the DSM of spiritual, religious, and moral traditions. So again, it aligns assessment, which the CFI helps assess cultural factors with diagnostic coding. And then empirically, Pargament and X-Line have done a lot of work outlining different religious or spiritual struggles and moral struggles is one of them. And there's validated measures of moral injury, they contain items for religious and spiritual struggles, the EMIS, which is the Expressions of Moral Injury Scale, which is very commonly used. Three of the 10 items are related to religious and spiritual distress. And then lastly, there's studies demonstrating the protective role of positive spirituality in moral injury and moral distress. And from a clinical utility perspective, highlighting the existential distress in patients potentially has clinical implications. So going back to Sarah's case, again, I'll read it again. She was a 28-year-old ICU nurse experiencing overwhelming feelings of exhaustion, despair, and spiritual distress related to her work. After an experience with the suffering of a young terminally ill patient, she found herself disillusioned by the conflict between her personal motivations for entering the field of medicine and her current situation. She feels betrayed by the lack of support from hospital administration, as well as guilt for the role she feels she played in contributing to her patient's suffering. And I bolded here at these, what I'll call these moral emotions. So disillusionment, betrayal, and guilt. Guilt being a internal moral emotion, but betrayal being a moral emotion that's experienced in the context of relationship. And so how would this be approached from PTSD-oriented therapies? Brett Litz has described this as a yes, but approach. So the therapist, in the case of Sarah, would say yes. These things happened, but offer a recontextualization. There were multiple factors outside of your control. You were doing the best you could. There were other people in a similar situation. So there's recontextualization of the events. And then there's a but. And the but here is where these emotions, such as guilt, shame, betrayal, feelings of betrayal, are treated as cognitive distortions, either that have been over-assimilated or over-accommodated. And through Socratic method CBT principles, these emotions would be changed over time, that they're malleable. Brett Litz has highlighted, among others, that this might be inadequate for cases such as these. Proposing a spiritually-oriented form of yes, dot, dot, dot, and, and the devil is in the details here. And so there is, again, a recontextualization. But then there's the dot, dot, dot. And what this is is when the therapist acknowledges, affirms, and empathizes with the moral component of the pain and the suffering, identifying that, yes, you did have ideals in coming into this profession that were not met by your experience. And that acknowledgement, affirmation, and empathizing is followed by an and. Instead of a but, treating the moral emotions as malleable, there's the and, which in the literature is mostly behavioral approaches, such as letter-writing to the deceased, or doing a positive act for the community that was harmed in the moral injurious event. And this is all to help make amends, to help that person restructure their worldview. So in conclusion, we've highlighted the need for more comprehensiveness in diagnosis. And by acknowledging these moral problems within the religious and spiritual struggles Z-code, clinicians can offer a more holistic diagnosis that includes the spiritual dimension of patients' experiences. This is important because moral problems can significantly impact mental health, and recognizing them formally allows for comprehensive care. In speaking with psychiatrists at the VA, about Z-codes, one of the things that they've expressed that would be positive with this change is that it legitimizes the construct for the patient. And so it allows for a conversation in the clinical context that legitimizes the patient's experience. And then it facilitates targeted interventions. This is what I outlined there with the yes, but versus the yes, dot, dot, dot, and capturing these more existential questions. And this is an area of recent research, and more research is needed here, but it acknowledges the impact on identity and values. And one of the things in high-risk populations such as veterans, but healthcare workers, is that the training environments foster unique identities and moral values. And oftentimes, between military and healthcare, there's a lot of overlap. The hero ethos, the altruistic motivations to do good and prevent or stop evil, but also a stoicism, a resilience. And you can see how some of those values could be ruptured in the line of work, but also how those values could actually perpetrate worsening of moral injuries, such as stoicism and the lack of acknowledgement of moral pain. And so more study is needed around how identity and values play, play and how this could affect training, how this could affect preparation for morally injurious environments. And then implications for clinical care. One of the things that we've highlighted is how potentially there could be a need for incorporating spiritual care providers, such as chaplains, into the treatment team. And this multidisciplinary approach can enhance patient outcomes by addressing the full spectrum of the individual's needs, and more research is needed here. And lastly, including moral problems in the Z-code could stimulate research into the effects of moral and spiritual struggles on mental health, and leading to the development of new evidence-based interventions targeting these issues. There has been work done in this space, but again, much research is needed. And with that, we have our references. Thank you, and we'll take some questions. So thank you for that excellent presentation. Deeply thought provoking. I find myself feeling very ambivalent because a question I wrote down as I was hearing this talk for myself is, is PTSD what happens when a society loses its capacity to mediate problems of moral injury? So I think about the history of PTSD as a diagnosis, which I tend to relate to the post-Vietnam era and the experience of veterans coming home from that war who were not able to feel reintegrated into the society after their experience because of the moral ambiguities at that war that the society was unable to itself integrate. And out of that came this diagnosis. And then I had a particular experience of doing multiple forensic evaluations of victims of clergy sexual abuse, which to me seems to be the paradigmatic case in many ways where we were framing deep problems of moral injury in clinical terms of post-traumatic stress disorder largely. There was depression, there were anxiety. Those things were all really there, no question. And it was very clear that they related causally to the issue, but the problem was that that the victims had nowhere to go because the mediating institution that had injured them was, had been for many of them their source of moral orientation. So my ambivalence is about what do we need? Do we need a Z code or do we need for our society to rediscover resources or mediating moral injury or are we just confessing that we're unable to do that and this is the rear guard action? Yeah, thank you for your thoughts and your question. I'll do my best to take a stab at it. Yeah, one of the things that has been noticed is that there is the moral injurious event itself, but then there's the response. And that response often worsens or perpetuates or even causes the moral injury. And at the APA last year, I went to a talk by a psychiatrist in Alaska who, her experience providing emotional support to her colleagues during the COVID pandemic was then met by her cultural milieus response to her that was saying, you are trying to hurt people, you are perpetrating governmental agendas. And it was a similar kind of the Vietnam reaction, going and wanting to be the good guys fighting the bad guys and then coming and then your community not accepting that or perhaps seeing the opposite and that can actually perpetuate the trauma. And I think one of the things that we wanna highlight with the Z code is one, that we're psychiatrists and we can't change the world, so we have to know our role. And in knowing our role, it should be in advocating for these societal issues. But also when it comes to a Z code, it's helpful because one, it's non-pathological. So it doesn't pathologize the construct. But two, it does affirm and acknowledge this construct to help move this conversation forward. And I believe in the infancy of moral injury research. And so we don't wanna take away from other initiatives, but we do hope it, at least for psychiatrists, it is a way of taking a step forward. And then lastly, I'll note it's an extremely pragmatic approach as well, because in the Vietnam War, 58,000 Americans died in combat and over 100,000 by modest estimates have committed suicide since then. Similarly, from the Gulf Wars, 60% of patients that have received treatment for PTSD in the VA, this was a study done in 2017, 60% noted no improvement in their PTSD symptoms on the PCL-5. And so moral injury is affecting these patients and I believe making their symptoms worse and even leading to suicidality, as those studies noted. And so this Z code is again, a way of acknowledging that and moving this forward. But great thoughts and yeah, thank you. I might just add to that question about clergy sex abuse and what needs to be done there. Len Sperry has written about what he calls sacred moral injury, which requires an institutional response as well as individual work with people to try to address it more adequately. First, I'd like to thank you, the panel, for the very nice presentations. I have two questions. One, the moral injury started first with the wrongdoings of the person that conflicts with their own moral values and spiritual values. But it seems that the concept of moral injury has been expanded also to actions behaved by other people. So I'd like to understand more about this expansion from our own actions to other actions. This is one point. And the second point, what has been shown more consistently the best therapeutic approach to moral injury? Thank you. Excellent questions. To the first question, there has been differences in the way that moral injury has been captured. Jonathan Shea introduced in the literature more philosophically in the 90s and then Brett Litz in the empirical social sciences in 2009. And they had differences on how to conceptualize betrayal, like these acts that were experienced at the hand of a trusted authority in the military setting. And then as we've noted and other studies have noted and other measures, this idea of being a victim can also come in witnessing events. So things that you're not involved in witnessing and perhaps you feel some personal moral transgression because you feel like it was an act of omission on your part and so the way that events externally to you affect your individual moral code is complex but it has been noted consistently that these other oriented moral injuries do impact people's chronic self-perception leading to these consistent emotions. To the second question, or do you wanna add anything to the first? I think the case the other gentleman mentioned of clergy sexual abuse, I mean that was sort of missed in prior definitions. And so that seemed to be relevant because the perpetrating party is sort of fragmenting one's worldview and entire moral framework and that's where, yeah, our group is not the only one who's sort of picked up on that. There's actually prior publications touching on this but yeah, so anyway, that's the connecting point. I think that the clergy abuse is a kind of a striking example of the victim, PTSD not being sufficient to capture all of the person's experience of distress, yeah. Do you wanna say more about the therapeutic approaches? Treatment, yeah, when it comes to treatment, Harold Koenig did a review, I believe in 2021 of treatments of moral injury and subdivided it into two potential approaches. One he called the secular approach and then the other the pastoral or spiritual care approach. From the secular approach perspective, there's spiritually oriented cognitive processing therapy has been proposed and studied but these are just case reports and there's one open label trial but it hasn't been rigorously studied. And then adaptive disclosure. And this is adaptive disclosure was brought out by Brett Litz and there's been a few studies, most recently a few months ago, published a multi-site randomized control trial adaptive disclosure versus person-centered therapy for moral injury. And what they found, it was a non-inferiority trial. So it didn't actually, on one measure, I believe it was benefit over the person-centered therapy but overall it's non-inferior, so it wasn't any worse. And so if you read the discussion around that, the discussion's half the paper because with studies like this, there's so many variables and the big push is like to not be discouraged about the lack of response from trials like that just because we're in the infancy of studying it. Another thing that Brett Litz has noted, we had the World Congress on Moral Injury a few weeks ago at the Harvard Human Flourishing Program that Jennifer hosted, she's not able to be here, and Brett Litz gave a talk and one of the things he noted, this is more anecdotally, is that it's very difficult for training psychologists who were the ones doing the therapy and being supervised for this trial, it's very difficult for training psychologists to be comfortable enough and confident enough to really sit with these moral emotions, that acknowledgement, that affirmation, that dot, dot, dot. It's very difficult for young psychologists to do that. And he noted this, and again, that's more anecdotal but it gives context to some of the trials that are coming out. So that's the secular side. From the pastoral and spiritual care side, integrating chaplains has been shown to be positive at a case report level, and then group therapy as well with pastoral care, kind of supervising that based on someone's religious or spiritual affiliation has also been shown to be positive, so. Hi, Dr. Devaney from Tripler Army Medical Center. I also am ambivalent, mainly because I was at the, when you said at the lecture the other day that the moral injury Z-Code was coming through, I was very, very, very excited. Still excited, but had the mental model, as you discussed, that it was gonna be its own category, and to the point of, I will say despair, seeing that it was only into the religious and spiritual. And as I was trying to figure out how to make my comment to a question of where this was coming from, I think the consideration, so the Army made a lot of efforts through a comprehensive soldier fitness to address the spiritual pillar. They had five pillars, and there was a fifth one, and there was a lot of debate, which I can imagine may be similar to the debate that happened back there as to you shouldn't include it, or there's connections with spirituality. They did end up keeping it in there with a lot of the same explanations of what you came up, their spirituality's not religion, it's about that common value. Ultimately, the end result was there was so much pushback, they did remove the spiritual questions from all the spiritual things in the comprehensive soldier fitness, and eventually the pillar just disappeared. So the fear is, and I guess that's the consideration as to the moral getting lost or disappearing from that, and also just some insight as to the considerations why that might not happen or the risk wasn't as big as combining it in with that category. Yeah, thank you for that context. You guys have any thoughts? Hmm. Yeah, no, I think that's a great comment. I mean, one open question is to what extent can you address moral injury without dealing with somebody's worldview, religious, spiritual framework? I don't know the details of that recent trial that Seth mentioned, but it might be the case that these treatments aren't as effective if you don't address this kind of fundamental religious, spiritual orientation. Oh, I'm too sorry, I forget my social anxiety. Oh, no, yeah, you do. Because I think, and also, too, it's obviously not just military, civilian, different views, although the military can be seen as a microcosm of the general public, but I do think also, it's just, some will connect to it, but then also values-based, you know, there are ways to have values-based that aren't connected to the religious point, and even with all the connections, it may just, and if my, when you were going through the information as to why you made the decision, if it's that separate, then why not keep them separate? I mean, you could say there's no harm in lumping them together, but then it just seems like if they do seem to march under different things, like values, that it doesn't have to necessarily have the religion section, only because they're not gonna read the fine print of what they see, and all they'll see is, they won't even probably see spiritual, they'll just see religious. Yeah, I think it's very important that it is named religious, comma, spiritual, comma, or moral problems, not and. Understood. Yeah, yeah. Again, it's just the natural of that, they might just gravitate towards seeing that first. And again, that's not the clinicians, it's not other things, it's just a concern, because I would not, that's super excited about the Z code, I would not. This would really help a lot with the military side, and I think military providers with having this. Thank you. Dr. Patty Figgs, I work as an outpatient provider, but also was in the Army Reserves for eight years, and worked as a psychiatrist in that realm as well. And we see moral injury all the time, right, from the young combat medic who's tasked with shooting all the dogs who come near the base, to the graduate student who had three years of data stolen by his advisor, right, like these things that are core events in this person's life, and they may not be manifesting symptoms that look like PTSD. And then you're sort of calling them depression or anxiety, but you know it's not capturing the essence of what the real issue is. I mean, maybe that's just my psychoanalytic background, but I love the ability to have this Z code to be able to say depression with moral injury, right, like that's so, so important, and I can't code for that in a way that feels right now, so thank you very much for that. And I sort of am echoing that sense that the religious piece is muddying. I think, especially for my younger folks, I very rarely see a religious affiliation anymore. There's so much of this, even the word spirituality can be kind of like, people are like, well, that's not me. You know, I'm agnostic or I'm atheist. But morality is a thing that most people can identify with and say, well, yes, I was hurt in that way. I identify with a sense of morality in some way. So I'm glad that the morality word has been included in there, although I do think that it may get pulled down with that religious or spiritual association. But thank you so much for adding this in. Yeah. That's one point I wanted to really emphasize in follow-up to what you just said, is that I think our main goal here was to get moral injury or moral problem into the DSM in this other conditions section so there's a way that we can relate our clinical experience that this is really something that we need to attend to into a concrete code and that you can then, you know, diagnose whatever mental disorder, you know, major depression, PTSD, whatever, and, you know, address it in whatever way, but in addition, we feel that moral injury, you know, does initiate, exacerbate, you know, complicate the treatment, of course, and outcome of the mental disorder and if you don't identify it and if you don't pay attention to it and incorporate it into the treatment plan in some way, our belief is that you will not have a good outcome as if you did address it. So by getting it into the DSM in this way, it allows us to begin to address it more concretely. Now the other thing that I think we also kind of alluded to is the, was the original thinking of the workgroup was to have this be a disorder, okay, but that upon further review there just was not enough literature to talk about it as a disorder and to get something in as a disorder, you know, that's a very long reach and I think we saw that in the example of the prolonged grief disorder, you know, it took years and years of research and data and studies to get prolonged grief disorder in as a disorder, but I think eventually our thinking or at least our ideas, my speculation would be that as the research develops, there may be an entity of something analogous to like prolonged moral injury that does reach that disorder level, you know, we have enough data and that could be proposed somewhere down the road and I think that that is still a possibility, right? Yeah. I mean, that's fantastic because how it affects the treatment plan, that's the key, right? You would never say I'm going to treat your moral injury with an SSRI. Right. Right. That doesn't make sense. Exactly, exactly. That's the point. That's perfect. That's the point. That's the point because right now if it's not in the DSM, you know, it's like well where is it? It's just like some conceptions that you're bringing in here, you know, what do you do with this? And you can just roll it, you can just ignore it and just go to the SSRI and the point here being is that we really do believe that holistic treatment requires this and this is analogous to religious or spiritual problem is that if a patient comes in, you ask them, well, what brings you here today? And the patient says, well, you know, I've lost my faith in God and God is punishing me on my sins. And you say, well, here, take this SSRI. I mean, that's absurd. And so the same thing here is that, you know, is that we have to address the moral injury. Yeah. Yeah. Thank you. Yeah. And thank you for your comment to highlighting the growing population in the United States. in 2022, they cited Gallup study of that growing population that is not spiritual, religious or religious because there are those that would say, I'm not religious, but I'm spiritual. But then there are also individuals that would say, no, I'm not religious or spiritual, but do hold to a moral or ethical framework that's perhaps connected loosely to spiritual religious traditions that are formalized, but it is their guide for an ethical life. And so, which I, which is why I, it is unfortunate that it could be pulled down by its connection there. But I actually see it. And I think the data supports that it's a strength because it makes this existential component of the distress unignorable by having it in the, in the title and connection there. First thank you. I really appreciate deeply what you're doing here. I'm Eric Carr from Tucson, Arizona. I'm a former Episcopal priest and now therapist. And I wanted to know, you said that religiosity does not actually help with suicidality in the cases. Does secular ritual or a secular spiritual program like 12-step recovery, has that been studied at all to see if that helps with suicidality? And then also you mentioned that the sacred moral injury, like the clergy sex abuse, we had an outbreak of that in my church in Tucson and it was never addressed. The priest that was involved just got sent to California to work with youth of all things. And so I know from personal experience that those institutional things often don't get addressed. And so that institutional response just doesn't happen. What do you do in a case like that when someone needs the institutional response, but it's never going to happen in their lifetime? Excellent questions. I'll leave the second to my colleagues. To the first question, to clarify on that study, the study showed that the level of religiosity that a patient reported was not the connecting piece between someone's moral injury and their suicidality. It wasn't the linking piece, but it also didn't, if someone is more religious or less religious, it didn't necessarily make them more suicidal or less suicidal. So that is not saying that religion and spirituality doesn't play a role in therapy or that it doesn't play a role in making the moral injury worse. And studies have shown that both happens, patients, especially in the military that are more religious or spiritual, they experience worse moral injury because of their worldview. And the treatment then should be appropriate according to their worldview. And that's one of the things with the cultural formulation interview that it helps with is the assessment of these cultural factors to bring more synchricity and integration to that patient's worldview and framework based on their experiences. The second question is very loaded. It's a very good one. And I think warrants a lot of discussion, but I don't know if you guys have any thoughts. I can add my two cents, I guess. I mean... Yeah, speak into the mic. Yeah. Yeah, those, I mean, those cases are really tragic, you know, and it's almost like the religious communities have sort of broken down forgiveness at a strictly sort of interpersonal level, right? This incident is between the victim and the perpetrator. Some of what we're doing, some recent work we've been looking at is sort of drawing on ideas from like the Catholic Church of when these kinds of cases of abuse happened, we have to recognize that the person's relationship, the victim's relationship with the church has also been severed. And you know, so if we just send off, you know, the perpetrator, that broken relationship with the church is not addressed. And so we need to figure out ways to do that. So we need accountability, so we have to hold that intention with forgiveness and justice. And then we need to think about these multiple layers of relationship that are basically severed, fragmented in the process of these abusive acts, you know? So it's not just at the interpersonal level, it's, you know, relationship with the church probably construed, one's relationship with the community in general. I mean, there's multiple layers that need to be unpacked and I don't think we do that. You know, my background is in psychology and I think most psychologists would just try to address the interpersonal level and not go beyond that. So anyway, there isn't a whole lot in terms of the forgiveness literature that I'm aware of that goes much broader than this. And I think your point suggests that we need to, you know? And so hopefully this will build over time, yeah. I've noticed the same patterns in the nonprofit world now that I'm working outside of the clergy. You know, people, it's like a congregation, you could call it a congregation. So they're alienated from their identity, they're alienated from their congregation, their spiritual family or their moral family. And I'm just noticing the same patterns in lots of different places. I mean, the institutions just never seem to be held accountable for that and how can we do that personally? You know, is there a ritual we can do or is the APA going to be the stand-in for that or how does it work? I think I'd love to see that addressed down the line, if possible even. Those are all excellent questions. I totally agree with you. I think, you know, religious communities need some kind of framework for dealing with this appropriately. I think the standard approach is, you know, try to solicit chief forgiveness as best as possible and try to move on, right? And that doesn't work, so. Thank you so much. Yeah. Thank you. I might just mention that Judith Herman, who wrote the classic book Trauma and Recovery, has a more recent book, Truth and Repair, in which she talks about the importance of justice for people recovering from trauma. So you might take a look at that as well. I can't hold myself back since someone else mentioned it. That's another thing that's been very much on my mind, which is that I would say among the patients that we work with, if anybody has experience with moral imagery, it is people with alcoholism and addiction. And of course, since that's the theme of our conference this year, I think it's worthy of mention. And it's very interesting from a clinical and therapeutic point of view to consider what 12-step fellowships have been up to now for almost 75 years, which is a very explicit process that includes, in one of the 12 steps, explicitly, two of them really, addressing moral injury. And that where, essentially, what is proposed, as we all know, is a spiritual solution to what we understand as a clinical problem. So the AA community is wary of study and the other 12-step communities, so I don't know if in your work it would be possible to access that in an effective way. But I do think it is something to be considered in light of the issues that you guys are considering. Yeah, I think that's a fascinating point. Just to extend what you've said here, I'm just to clarify what you said. Are you saying that, of course, we focus on the mental disorder of some sort of substance abuse disorder, blah, blah. Our traditional focus is to treat it in that way, but that related in some way to a subset of people with substance abuse disorders is moral injury. Now whether the moral injury came first and then the substance abuse or vice versa or what that relationship is, but in some way, moral injury, moral distress, is connected. In what ways, there may be different subsets. But the point being that you're saying, if I understand you correctly, is that the 12-step process, you mentioned there are two steps that deal directly with moral injury and that we can maybe take a look at that. I don't know to what extent people have written about that or maybe this is commonly known. But the point being, if the 12-step process deals with moral injury, that is an efficacious approach to supplement whatever work that we're doing. So I think you bring up a very, very important point, it seems to me. I would go just a step further and say I think that alcoholics and addicts, at least those who identify with membership in 12-step fellowships, would say that moral injury and the attendant guilt and shame are central to the disease. They are the nature of the pathology in many ways and that what they learned is that they needed to find a way to address that and that's basically the story of AA. So it's not so much a question of causation or effect as it is something that in the 12-step experience is understood to be inextricably bound up in the nature of the problem. That's absolutely fascinating and I think by getting this category in the Z code, it opens the door that we begin to actually document this, the extent to which this happens and to what extent does the 12-step process relieve symptoms of moral injury. I mean that's the potential here in terms of stimulating empirical research. I think it would be very helpful and that in turn would alert us in the field of psychiatry to really pay attention to this and really address it and that's the idea. Thank you. Yeah, the fourth and fifth steps are the most explicit but if you think about making amends and paying it forward, there are more than just two steps that have to do with that. I agree. And Donna Ames in that study in 2019 found to build on your point that of the 10 items in their moral injury scale they used, the factor that loaded on the strongest to suicidality was self-condemnation and that is also what you're alluding to is the emotion that's being numbed by substance use and so the connection there between substance use and suicidality I think is important to note. Okay, and if that's all the questions we'll conclude, thank you all for your attention.

moral injury

DSM Z-codes

PTSD

clinical care

mental health

religious context

spiritual context

therapeutic approaches

multidisciplinary approach

identity factors

cultural factors