Photo by  Joao Tzanno  on  Unsplash

Photo by Joao Tzanno on Unsplash

 

Shame, betrayal, guilt, anger. As social animals, humans are wired to have moral emotions that bind us to our groups. When we experience a transgression against our moral values, we might experience Moral Injury. Moral injury is a normal human response to a violation of our strongly held moral beliefs, and it can have a deep impact on people’s lives, making it difficult to move forward. In this episode, Debbie interviews two psychologists who are researching moral injury with veterans, Dr. Lauren Borges, and Dr. Jacob Farnsworth, about this cutting-edge and important topic in psychology.

In this episode you’ll learn:

  • What moral injury is, and types of situations in which people might experience morally injurious events.

  • How moral injury can impact people’s lives.

  • Why we have moral emotions like guilt and shame.

  • How PTSD and moral injury are related, and how they are different.

  • How Acceptance and Commitment Therapy might be a helpful approach for working with people who are struggling with moral injury.

Resources:

Dr. Lauren M. Borges is a clinical research psychologist at the Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for suicide prevention. She holds an academic appointment of assistant professor in the Department of Psychiatry at the University of Colorado School of Medicine. Dr. Borges’ primary line of research concerns the use of contextual behavioral interventions to help Veterans approach emotions like guilt and shame more flexibly. She is a principal investigator on a federally funded study focused on investigating the acceptability and feasibility of Acceptance and Commitment Therapy for Moral Injury (ACT-MI). She is also interested in using skills from Dialectical Behavior Therapy (e.g., the chain analysis skill) to help Veterans identify and intervene on their suicidal behavior. Beyond her focus on interventional research, Dr. Borges is developing and validating novel approaches to measuring facets of responding to guilt and shame.

Dr. Jacob Farnsworth is currently a staff psychologist at the VA Eastern Colorado Health Care System. Jacob’s primary research interest is in the area of military-related moral injury. His most recent efforts have focused on the further development of the construct’s definition, assessment approaches and comparing existing and novel intervention approaches for moral injury. He is a co-author of the Expressions of Moral Injury Scale-Military Version.

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Episode Transcript

Jake Farnsworth:  so first you have this moral injury injurious event, which violates your values in some kind of profound and deep way. We would argue that a natural and expected consequence of you having your values violated is the experience of what we call moral pain. And moral pain refers to the uncomfortable, dysphoric emotions, thoughts, sensations, urges. That accompany the violations of your value.

Lauren Borges: We don’t pathologize moral emotions or cognitions. We don’t try to reduce guilt or shame that someone experiences. It is not about that at all. It is about cultivating willingness to experience those emotions for the sake of what matters to you. Cultivating willingness to kind of. Step outside of a thought or step outside of a story, right?

Debbie Sorensen: That was Dr Jake Farnsworth and Dr Lauren Borges on psychologists off the clock.

Diana Hill: We are [00:01:00] three clinical psychologists committed to cutting edge integrative and evidence based strategies for living well,

Yael Schonbrun: On this podcast. We bring you ideas from psychology that can help you flourish in your work, parenting, relationships, and health.

Diana Hill: I am Dr. Diana Hill practicing in seaside, Santa Barbara, California.

Debbie Sorensen: I’m Dr Debbie Sorensen practicing in mile-high, Denver, Colorado

Yael Schonbrun: And from coast to coast. I’m dr Yael Schonbrun a Boston-based clinical psychologist and assistant professor at Brown University.

Debbie Sorensen: We hope this podcast offers you ideas for how to live a full and meaningful life.

Diana Hill: Thank you for listening

Hi everybody. We have some great events coming up in the new year. We want to tell you about, I’m going to be in Santa Barbara at yoga soup presenting a workshop on committed action. So if you have a change you want to make in the new year and you want to do it in a way that is sustainable and values based, meet me at yoga soup on January 5th.

From 2:30 to five [00:02:00] and if you sign up before December 20th you’ll get a discounted rate. You can find out more information@yogasoup.com.

 Debbie Sorensen: If you enjoyed episode 102 Dr. Steven Hayes, who is the co founder of ACT and wrote A Liberated Mind, we are having an online question and answer session about A Liberated Mind. It’s a great chance to talk to Steve Hayes directly, ask him questions, and listen to him talk about the book.

That’s happening on Tuesday, January 7th at 9:00 AM mountain time. So do the math on the time zones if you need to, and you can go to www.Impactpsychcolorado.com for details about how to join us live. And if you are a mental health professional and identify as a woman, please come to Boulder, Colorado on March 7th I’m doing a professional development workshop with Dr Meg McKelvie. You know, as women and mental health professionals, we have a lot [00:03:00] to balance and we can’t get really depleted sometimes. And this workshop is about tuning into our professional values, recharging our batteries, and coming together to support one another in our professional and personal growth. And we really welcome everyone, from students and graduate school to seasoned mental health professionals to join us. It’s going to be a wonderful event. And so also for that, just go to impact psychology, colorado.com for more information.

Diana Hill: we have links to all of these events on our website, off the clock, psych.com check it out.

Debbie Sorensen: I’m bringing you an episode about moral injury and shame, and to me, this is a pretty cutting edge new area that I’ve been learning about as a clinician. I think it’s very helpful to think about shame. It gets overlooked a lot with clients and often when people have. Done things in the past that violate their own moral code that can get really deep into shame and moral injury.

And in this [00:04:00] episode, Lauren and Jake talk about how moral injury is really tied to these moral emotions that people have. And we have them for good reasons, and it can be really problematic for people when they are in shame and they get stuck there and they. They might do things that are problematic in their lives.

And I have to say as a clinician, now that I know a little bit about this, I’ve started to pick it up occasionally in my clinical work clinical work where I might not have before. I’ll be sitting with someone and they’ll be talking and I’ll be like, Oh, you know what? This is moral injury. And I think just having the awareness of it and also recognizing the emotional and social impact it has, it can have on people has been really helpful for me as a clinician to know about.

Diana Hill: the episode really focuses on more extreme cases, and that makes sense. Like, uh, combat situations. The researchers that you’ve talked to, Debbie, you work at the VA and have met with people that have seen and done really, really hard things in their [00:05:00] lives, but there’s also ways in which moral injury and shame shows up.

I think. For many of us, and I’ve, I’ve seen it in my practice as well. Some of the places where I’ve seen it have been things like in relationships where one partner maybe has had an extramarital affair and they Harbor so much,  guilt and remorse about it, that it can actually get in the way of them moving.

Forward in, in, in the repair of that affair. Another place that I’ve seen it a lot is in the,  addictions,  certainly with eating disorders where people feel so, upset with themselves about things that they did while using their, eating disorder or while in their addiction that it actually leads to the cycle of more addiction because you use the addiction to try and mitigate the feelings that you have around it.

And. I think that what’s interesting about their approach is that it’s not about trying to [00:06:00] cajole the client and or your friend or whoever else may be coming to you with a moral injury. It’s not about telling them they shouldn’t feel bad about what they did because actually the feeling bad about what you did, links to your values and what you care about, and there’s a reason why you feel so intensely, about this and why it’s gotten so stuck for you.

Debbie Sorensen: Yeah, I’ll, I’ll add another area that I’ve heard people talk about moral injury a lot, which, and, and they actually alluded to this a bit in the episode, which is about physician stress and burnout. I don’t know if you’ve heard about this, but physicians and health care workers, um, are experiencing really high rates of stress and burnout.

And they work in systems often where they make really hard decisions. Sometimes they have a lot of. Moral responsibility to make the right decision, potentially save lives or not, and sometimes they’re actually not even able to work at the highest standards of their professions because of all the pressure that they’re under.

For instance, we talked to Cynthia Li recently about [00:07:00] how. Having the time to really get to know your patients well is really important and provides the best care. But sometimes that’s just not possible. And so there are some people, I’m Wendy Dean and Simon Talbot are leaders in this who are really saying that.

Physician burnout phenomenon is actually really a moral injury issue. It’s not so much, you know, just they’re stressed and tired. It sit there at some sort of moral crossroads with their work that’s making it very difficult to keep doing it.

Diana Hill: I can totally relate to that, Debbie, and when working with a suicidal client.

Or having a client that attempts suicide and how the therapist could feel like that, that they’ve committed a moral injury if their client attempts or if their client becomes a very suicidal because you’re at, again, like at this crossroads of what can you do. To help this person. And did you take the wrong road?

Like, did you do the wrong thing? Did you, should you have hospitalized him that [00:08:00] day? But then you let them go. And we’ve talked about that. And in cases that, um, you know, we’ve consulted on together, Debbie.

Debbie Sorensen: Yeah. I mean, the first thing that crosses your mind, you care about the person and you want to help them and you’re thinking, could I have done more?

Yeah. And I think it’s a lot of moral weight that we’ve put on ourselves to take responsibility for people in that way. Yeah.

Diana Hill: Yeah. So this episode I think will be so helpful for many of us, I, in terms of what to do when we’re at that crossroads and when we experience a moral injury.

Debbie Sorensen: Yes. Let me introduce Lauren and Jake.

Lauren Borges is a clinical research psychologist in the Rocky mountain, my rec, which is a VA research center. She’s doing some really exciting research on moral injury, especially act for moral injury, and she looks at other contextual behavioral approaches to intervening on. Difficulty responding to shame.

Jake Farnsworth is a clinical psychologist at the VA Eastern Colorado health care system in he’s a eight, a substance use and PTSD specialist [00:09:00] providing clinical services to people who have co-occurring PTSD and substance use. And Lauren and Jake also have been collaborating with a team and they wanted to acknowledge their team that they work with.

Uh, Robin Walser, Kent Drescher, Sean Barnes. Wyatt Evans, Lisa Brenner, Jason Nieuwsma, Joe Currier, and Craig Rosen too. So thanks to all who are doing research in this important area. We’ll link to some of their articles and publications on the show notes for today’s episode.

Diana Hill: Yeah. It takes a team to do this type of work, and I know all those people are major contributors to what they’re talking about today.

Debbie Sorensen: Yes.

so let’s start with the basics. What do we mean by moral injury? What is it?

Jake Farnsworth: Yeah, so this is a great question. So, the idea that there’s moral distress, you know, associated with traumatic events is, is certainly not a new idea that has been around for hundreds, if not thousands of years. what is more new is that in since 2009, one of the seminal article by Brett Litz was published. moral injury has [00:10:00] kinda been given a name and a research kind of, thrust behind it. So. since 2009 when that seminal paper came out, a number of different people, I’ve tried to kind of provide definitions and clarify what we mean by this thing called moral injury. And Lauren and I and our research team are no exception to that. So we, we have our own perspective of what that is. We would break moral injury down into three key parts. Okay. The first part is a morally injurious event or a morally injurious experience. This is a situation that isn’t, and it takes place in a height. Stakes context and involves the violation of core beliefs, moral beliefs, or values. Okay. So, thus far, the primary amount, the, the, primary area where this has been researched in is in military context. But, um, as this kind of continuing to kind of ex the contract is continuing to evolve and grow, it’s quickly being seen how this can apply to other domains as well, which we’ll talk about more in a little bit. Um,

[00:11:00] so if, um, someone does something unfair, we feel anger, right? If someone does some, if I do something that violates my own values, I might feel guilt or I might feel shame. And so just like if you get cut, right? Pain is the natural and expected response of your body responding to that injury. In the same way, if we have a morally injurious event, we would expect there to be pain. If we’re not feeling pain, that actually is a, is a, a bigger problem in a lot of ways, right? So, um. Well, we would turn moral injury then is not the pain itself, but rather the individuals’ ineffective, unworkable or costly attempts to kind of control, manage, or solve the pains to make it go away. So, um, that can happen to a lot of different ways. But you know, when we think about social isolation, we think about substance use, alcohol. I’m working distractions. There’s, there’s a whole multitude of ways in which an individual might try to avoid that pain, but end up making that pain actually get worse. So to break it down, so the morally injurious [00:12:00] event is the experience itself. The moral pain would be like the consequence, the natural consequence from that event and the moral injury would be the ineffective strategies that try to, we try to use to get away from the pain. But. W that are either costly or ineffective.

Debbie Sorensen: Okay. So it’s not just the event itself, it’s the, it’s sort of the aftermath in terms of moral injury to the person in terms of effectively responding

Jake Farnsworth: in the same way we might separate like a traumatic event and PTSD is separate, a morally injurious event from a moral injury, which is the response.

Debbie Sorensen: Okay. So the, so when a person has had this history of doing something that it’s against their own moral coal code or sort of a moral injury event, as you say, how does that tend to, what does that look like later? Like how do you see people struggling down the road when that’s the case? It

Jake Farnsworth: depends a lot on the nature of the morally injurious event. And I probably should’ve said a second earlier, that the MIS morally injurious events can happen in different ways. So for example. Um, you could have someone betray you, right? So you haven’t done anything wrong, but someone else [00:13:00] betrayed your trust. And so we would expect like anger would be a really pro, a natural emotion does to flow from that. Um, or you could see, you know, one person act out against another person in a way that betrayed your values. Know you just witnessed it and you might feel contempt or discus by witnessing that happening. Now, if you are the party, that dude, your own choices betrayed your values, you might be more likely to experience guilt or shame. So. It depends a little bit about the constellation and the factors of the morally injurious event itself and what the moral injury will look like. But oftentimes what we see, I think across the board would be kind of this overarching social disconnection, right? Morality is inherently social. And so when a person feels guilt or shame, they often feel like they don’t deserve to be there. They don’t deserve to be happy. So they might pull away if they feel like the world or in people important to them have betrayed them, they might, um, push back, right? Or push against those people. And, and. Kind of disconnect in that way. Um, we also see from people experiencing like a loss of empathy, um, when they [00:14:00] have their morality betrayed, especially if it’s in a routine kind of consistent way that happens over and over and over again. Maybe as part of their job, they just build up these layers of numbness and distancing. And so in some cases, people even kind of lose a sense of, um. Memorial bearing, and they might have a sense of moral disillusionment that there really is no such thing as right and wrong, and it makes it very hard for them to integrate them into our society, which has this kind of ideas about what is acceptable, what’s not acceptable. Um, and oftentimes of course, spiritual or religious concerns can be wrapped into that as well. And then kind of going along with our, our definition of moral injury. I think the other thing that I would say in addition to social disconnection is the kind of the negative, right. Effects of the coping strategies. So you might not actually see the moral injury itself playing out, but what you might see is really heavy alcohol use or drug use or isolation. Working a lot, like these kinds of things, or the person is Coke trying to use to cope with their internal internal experience of pain is what actually might rise to the surface [00:15:00] more

Lauren Borges: multiple suicide attempts. Yeah. That’s something we see often too, associated with moral injury, and there’s a lot of literature coming out that’s, I’m starting to support the relationship between moral injury and suicide. Yeah.

Debbie Sorensen: Wow. So there’s a lot of different ways that that shows up. Yeah. Yeah. So you both work with veterans and talked earlier about how military, this often happens in a military context, and I think people could imagine things, ways in which that might show up in combat situations or different atrocities. What are some other ways, or can you give some examples of types of moral injury people might experience.

Lauren Borges: Yeah. Absolutely. so I think I w I want to highlight a couple of things Jake said related to, warzone veterans first cause I think they’re important and then we’ll kind of expand a little bit to, to outside of a military veteran population. there are, there’s actually a whole intervention dedicated to the impact of killing, which I think is really interesting. Interesting. So that’s a morally injurious event that we, that we see often in the people we work with. [00:16:00] And I want it to highlight something else you said about, because I think this is often something that we sometimes don’t think about as a moral injuries event. Um, an act of omission. So something where I’m, I’m witnessing an atrocity or I’m witnessing something that I don’t believe is inconsistent, that I believe is inconsistent with my values and should not be happening, but I don’t intervene. Right? So kind of objectively, it looks like you did everything you should have done, like you behaved exactly as you should have behaved, and yet you violated your values by not acting. And that’s something that we’ve both seen a lot in our groups and in some of our individual work just witnessing atrocities. And I think that that piece really applies to civilian populations too. Um, I think if you think about something like witnessing a motor vehicle. And not being able to intervene and seeing death associated with that. Um, being involved in a natural disaster and not being able to help other people and save the lives of other people. There’s an example that we use in some of our, like workshops and clinical presentations [00:17:00] with a client that one of us worked with who, um, was so heavily using substances that his, uh, children were sexually victimized as a result, which is, uh, another example of a, of a morally injurious event that certainly doesn’t . STEM from war, but it’s very obviously, um, shame of Woking and getting caught up inside of, of that story definitely affected this individual’s functioning. Um. I think we, we’ve also had some people in our group who, um, have morally injurious events from prison. So something like a gang initiation or just behavior that I had to engage in, in prison for the purposes of survival. And now that I’m outside of that, like, how do I, and I think this is an important piece, like how do I, um, kind of hold these two behaving, uh, related to two different value systems, right? So if I’m, if I’m over in war and I have to like subsume kind of the value system of the military, and then I come back and now I’m. Faced with all these cues of, of what I care about in my community. Like how do I hold those two things at the same time? And I think that’s, that’s true for, um, people [00:18:00] who are in prison and, and other contexts as well.

Jake Farnsworth: Yeah. Also, another area where moral injuries really being explored right now is like, um, with physicians, um, people in the ICU who have to make really split second decisions that will impact these patient’s lives forever. Whether to amputate the limb. Um, or make other kinds of critical life or death decisions. Um, same as true for first responders, paramedics, firefighters, police officers who, um, police officers, particularly because they have the potential to use lethal force, but, but also a paramedics who have to kind of make decisions about who gets treatment first. Um, and, um, inability to kind of render. Necessary aid sometimes, um, or, uh, there’s also been some exposure to like, um, or some exploration of people exposed to child sexual abuse, like, um, uh, child protective services and going into these situations over and over. We have vulnerable populations, um, being exposed to kind of, uh, inhumane or [00:19:00] abusive context, but not necessarily be able to do anything legally. So, so there’s a lot of, kind of interesting exploration right now about how far. The moral injury Crow construct can and should be extended. And that’s kind of a nebulous area right now. Yeah.

Lauren Borges: I think a lot of different people are doing work in this area and the measures that we use to, to kind of, um, identify exposure to different kinds of Morley injuries, events were normed and developed explicitly for warzone veterans. But there are other investigators that are looking at this and other populations. So I think the next, um, 10 years will be really interesting for this field.

Debbie Sorensen: Do you think that people know that they’re doing something morally wrong while it’s happening or while they’re doing it? Or can it sometimes be retrospective? Like they don’t really realize it’s a problem at the time and it’s only later?

Jake Farnsworth: Yeah. Yeah. It happens in lots of different ways. Um, so, um, there are some qualitative research that suggest like, that some people know in the moment, like in the moment, it just hits them in that way and [00:20:00] they realize this is wrong. But either because they choose not to or they’re unable to. Um, the events still happens. So certainly that occurs. But there are other cases that we see both in our, anecdotally in our clinical practice, um, where individuals at the time thought that their actions maybe were justified or that what was happening is what should’ve happened. But then afterwards, maybe especially as Lauren said. When they change contexts, like, so for example, um, service members, oftentimes these events happen overseas in war zones and, um, there’s an entire culture there. There’s a set of SOPs and rules of engagement and, um, what we know as, as humans that were highly influenced by our environments, right? So when a person is in that kind of social context with her, maybe they’re, they’re, uh, don’t have much time where their life is on the line. It can stoke a lot of moral emotions. Um, that can. Uh, make us more inclined to make moral decisions that we otherwise wouldn’t do. And it’s [00:21:00] not until the individual comes back, like into the civilian sector and has some time and some distance from the event to really consider what was happening. And that sometimes they re they recognize, wait a minute. Like, who was I? I was someone else over there. And oftentimes, like narratively, we get this sense of, I was a different person in that situation. And I even say that goes the same for some people in the midst of their addiction, right? Like the, it feels like it was a different person who was doing things and yet it’s still me. You know? It’s the same names. Same a, a social security number. And so how do I reconcile that, that I was this different version and did these things and now I find maybe wrong or, and reprehensible, right? Or that I was, uh, and on some way, even a part of it. So I think sometimes, um, with veterans, especially as they come back, they look maybe, um, at the broader kind of political, uh, context of our recent military engagements. And maybe start to question what was that for? And is, was that really the reason why I was . Thought I was [00:22:00] going over there to begin with. And so sometimes that can also create a sense of kind of disillusionment that what I signed up for is not really what I was enrolled.

Debbie Sorensen: Right. It’s bolted doing more complicated than some of the, you know, like world war II where people had this clear sense of like, we’re doing this for a. Very clear moral reason. Some more recent engagements, Vietnam and some middle Eastern. It’s less clear what they’re doing and why,

Jake Farnsworth: and then that increases the complexity. And, um, even in world war II, there are some, we didn’t have the term moral injury, but there are certainly some writings in terms of, one of the things we didn’t point out is that moral injury can also come just from observing in intense human suffering. Right. Um, and so that, that’s another way I would say. And certainly, um, you know, acts of atrocity in, in humanity happened. Absolutely, yeah.

been a part of our heritage as well.

Debbie Sorensen: Yeah. And that was a pretty US-centric thing I just said, cause if you were in Germany, so I was [00:23:00] talking to one of my podcast cohost, um, Diana recently about this interview and we were, we were in the car together and we started talking about things we’ve done that we feel guilty about, like smaller scale things. Do you think. Those, so things like, for instance, you’re not paying attention on the road and you hurt someone, or you’re as a parent, like, you know, when you yell at your kids, even though you don’t think that’s a good idea. Like do you think that there’s degrees of moral injury events?

Jake Farnsworth: Yeah. Yeah. That’s a, that’s a great question. Yeah. So, so yeah, we can think about this. This is actually a, is an important question because moral injury is kind of an intuitive concept. Right? And so when people hear it, like when I, when I talk about PTSD with people, they’re like, what’s that? You know, like they’ve heard of this thing, but they don’t really get it. When I say moral injury, everyone immediately goes, bingo. Like, I know what that is. Like, how do you know? How did you find out? Right.

Lauren Borges: I think just like the weight [00:24:00] of the term, more moral , like what is that in an equivalence class with elicit. So much about me, the world. So I think that makes a lot of sense.

Jake Farnsworth: Yeah. So, so I think, so one piece, they recognize the morality is a fundamental part of our human experience, right? Like as social beings, we have to have a way to kind of know how to treat each other. And that’s kind of really where morality lives. And so we’ve all had moral experiences. We would all, I would say based on our definition, we’ve all experienced moral pain now. Um, if I could maybe use a parallel to kind of help us understand your question though. So. Um, we think about PTSD. Um, have you ever had a nightmare before, right? You’ve had a nightmare, right? I’ve had a nightmare. We’ve all had at least one nightmare in our life. Have you ever felt maybe a little on guard or edgy because of this situation you were in? Probably. Right. Um, have you ever not done something because of how it was going to make you feel? Right. You know, and so of course, we’ve, we’ve all done, we look at the symptoms of PTSD. It’s separately. We could [00:25:00] all probably resonate with them a little bit too. Right. And statistically everybody, not everybody, but the majority of people in the U S at least have experienced at least one traumatic event at sometime in their life. Right. So what makes the difference then between someone who has experienced those things and someone who has the diagnosis of PTSD? Well, I would say one is the number of symptoms that you’re experiencing, the intensity of those symptoms and duration, and the functional impairment. Right? So just because like I’ve experienced a nightmare. It doesn’t mean I have PTSD. So one of the things that’s important is to look at the severity of what we’re seeing here in a clinical sense. I think another piece to look at is kind of the functional relationship, right? So, um, maybe we’ve all done things that, you know, live kind of came short of our values, right? What was the effect of that? Right? Like, so when we’re talking about moral injury, first of all, we’re talking about a high stakes environment. We’re not, we’re not talking about like getting a parking ticket. Right? We’re talking, we’re talking, we’re talking about things that kind of fundamentally altered the course of people’s [00:26:00] lives. Right? Were, were lives were lost, or I’m having kind of serious implications for people’s quality of life longterm. And then the other piece we’re saying, and we’re looking at functional impairment, we’re looking at kind of pervasive, significant impacts on people’s ability to connect with what they value most. So for one example, there was one individual who, um, really, uh, you know, lost the ability to feel love for his family. That’d be worked with. And even though he was holding down a job, right. But he wasn’t, he was a military veteran and he was involved in, um, per his count due to his job, like hundreds of deaths of civilian deaths overseas. And, um, it was all according to rules of engagement, but it was kind of part of that ominous term, collateral damage. And, um, he really lost the sense that you started seeing people in terms of numbers. And he brought that home with them so he could sell his own family as numbers and he couldn’t break out of that. Right. So that that goes beyond a sense of like, Oh man, I really shouldn’t have done that. Like this is much more pervasive, [00:27:00] intense, and functionally impairing when we’re thinking of the construct of moral injury.

Lauren Borges: And I think that’s something that can go along with that. And something we really target in treatment. We’ll talk a little bit about act for moral injury later. Um, is this perspective shift that can happen or, or kind of if I have this perspective already and I experienced these morally injurious events, it can just become ingrained even more so that, that really individuals kind of get caught up in, um, stories about themselves related to what happened in, in a way that, um. Is is so kind of debilitating and paralyzing that I’m kind of trapped inside of that story. Now we’ll kind of go more into that in a second. So it’s become like a really big thing in their life. It’s really imperative. All I can see those minor things that we all experience, they’re just kind of like a much, much lower level.

Jake Farnsworth: Don’t take it like a central role. Like in drama studies, there’s this idea that events and travesty that like this event now becomes like the center node of my life revolves around it. It’s like the hinge upon my life turns. And, and for many [00:28:00] people when they have experienced a severe morally injurious event, it’s like that. It’s like, this is the kind of the fulcrum upon blueprint life is turning now.

Debbie Sorensen: Takes over. Yeah. So we’ve been talking about PTSD and we’ve talked about moral injury, which seems like they often go hand in hand. What’s the difference between the two?

Jake Farnsworth: Yeah, so they are highly correlated and the research is saying that they happen together. And this is an area of active kind of discussion right now. And so, um, what we’ll share today is kind of our thoughts about why the construct of moral injury maybe doesn’t fit so well with PTSD. So I’d say there’s, there’s four main reasons. Um, so one is that PTSD is a DSM diagnosis, which means by definition, it’s a sign of pathology, right? That something has gone wrong and we are expect, like sometimes we talk about PTSD as a failure to recover, and we would expect people to kind of be able to bounce back from these events, maybe sometimes with some help. Um, but we would expect it to be an actual recovery. Now, when we think about a morally injurious event and the moral pain that a person experiences from that, as I said earlier, you know, if, if you get a [00:29:00] cut, we expect you to feel pain. That that actually means that something’s working right. Even though it’s uncomfortable, even though it’s hard. Like what, what maybe colloquially we would refer to as a conscience. Right. We think that serves an important function for the person to be able to kind of recognize when their vital values have been violated. So for that, like I worked with one client, um, and I diagnosed him with PTSD and he met the criteria. But what he actually said to me when I gave him the diagnosis, he rejected it. He says, no, I will not accept the diagnosis of PTSD. And he explained, I don’t have PTSD. I have a conscience. Which was a really powerful impact for me. You know, to realize I wait a minute, like I’ve been medicalizing this thing that this person actually sees as a, as an ethical issue. And so that’s one reason why we think it’s important that that moral injury not be classified as a DSN diagnosis because we don’t want to pathologize conscience or

sense of values.

Debbie Sorensen: That’s a good thing that people have a sense of morality and a conscience,

Jake Farnsworth: and then we feel bad when bad things happen [00:30:00] like that. That’s actually a good thing. So, um, so that’s when we way is different than PTSD. Another is that, um, in order to have a PTSD diagnosis, you need to have what’s called a criterion, a trauma. And that involves by definition, um, serious injury, loss of life or sexual violence, because those are the only kind of thing, three things that will meet that criteria. And you can have a morally injurious event that doesn’t involve those things. Like I had one client who for his job had a bulldoze houses. Of people who were very poor, so they’d be standing on the side of the road while he just demolished their entire life and livelihood in order to make way for this convoy. And, and so no one was in danger. No one lost their life. There was no sexual violence. So it doesn’t count as a criteria in a trauma per PTSD definition. And yet that stuck with him for years and years and years. So that’s another reason why moral injury doesn’t necessarily fit the criteria for PTSD. Um, another one is that, um, PTSD is largely still a fear based diagnosis in the latest [00:31:00] DSM has been pulled out of the anxiety disorders. But you see a lot of the vestiges still there in terms of hypervigilance start over res respect, reflexes and other things like that. So, um, it’s still largely a fear-based diagnosis and moral injury clearly is about guilt, shame, anger, and, and other moral emotions and experiences. And the last one, um, that I would say that is important as really clear implications for treatment is that, um, PTSD, in order to have, um, your thoughts be associated with PTSD or fall under that umbrella, they need to be distorted or exaggerated. That’s just a part as written into the actual definition of the criteria. Um. In order for something to be distorted or exaggerated, you have to be able to prove it. It’s an inaccurate, right? You have to be real show, like with objective evidence that this is why it’s not accurate. And we do that at PTSD treatment and that’s like people might say it’s dangerous outside and say, well, let’s, how often are their bombs going off? Like how often are there shootings? And it feels like a lot until you actually do the [00:32:00] numbers. And actually we live in a very safe part of the world. So. Um, in contrast, you know, PTSD is about, it’s about what it is. Um, moral injury is about what ought to be. And so, for example, a person who could say, you know, I know, um, that there were reasons why, you know, what happened, happened, but I still feel like I should have done something. Like we have people who, um, will maybe saw like a rape happening and they were ordered not to do anything. Right? So there was this clear like, command, no, don’t do anything. And maybe they complied with that order, but now in retrospect, you think. I should have done something right. Like I should have taken action. So moral injury and moral values are really about what ought to be, not necessarily what is right. And there’s a discrepancy between those two. So, um, and you can’t prove a, an ought to be accurate or inaccurate. Right? It’s very subjective. It’s a value. Yeah. So, so we can, so for that reason, by definition, we would argue [00:33:00] that moral injury does not fall within the criteria for PTSD.

Lauren Borges: And when you’re focusing on what is right, like you did everything you should have done, you’re not kind of targeting how someone’s relating to the, to their guilt and shame. You’re, you’re targeting, you’re targeting something else. So I, I think, um, Jake’s point about, uh. PTSD being characterized for a really long time as an anxiety disorder is a really important in thinking about how interventions, how ABPs for PTSD were set up, um, and kind of set up with that conceptualization in mind, which certainly doesn’t mean that they don’t target guilt and shame. Um, we, we would argue that our intervention primarily targets, um, how individuals are relating to guilt and shame and other moral emotions

Debbie Sorensen: while speaking of guilt and shame and moral emotions. You do talk about. Um, shame as a moral emotion that has been . Purpose. Can you tell us about why humans have shame?

Lauren Borges: Yeah. Yeah. So I think there are, there are a couple of different levels here that are important to consider. [00:34:00] I think, I think the first is evolutionarily why we have shame. Um, shame is an emotion that actually motivates incredibly effective behavior for the purposes of human survival, right? If I consume too many of the group’s resources, I should feel shame in response to that because that will temporarily remove me kind of from the tribe, from the . From the bigger picture, which is, which is really important if we’re thinking about kind of the greater good and the collective sort of staying intact. And there’s, um, some cool research that, uh. That kind of relates shame to the social system social safety system,  so, so I think, I think part of this is like humans are hardwired. Really to be socially connected. And so that kind of the other side of that is, well, what do I do? What, what happens when I do something, um, that is, uh, socially not acceptable? I feel shame as a consequence and we actually argue that, that you should embrace that, right? So, so, so embracing shame and moving with shame for the sake of what I care about is [00:35:00] critical, um, in, in the way that we approach shame clinically. But. Unfortunately, that’s not the message that we get in our culture. That’s not the message that we get in mental health care. I would actually argue as a whole, shame is pathologized. It’s something that you shouldn’t have. It’s something that we, we try and work to reduce. Um, which, which I think is not, is not kind of harnessing the power of what this emotion is. And. And, um, how it, how it functions to keep us together. So I, I think that’s kind of the importance of considering shame at the level of the group. And then I think we get into shame at the level of the individual and what does that mean? So if we know that evolutionarily we should have this experience and this experience keeps us connected and motivates prosocial behavior, um, if we think about it, the level of the individual, it’s really interesting because. Um, so now I have this emotion of shame. Of course I do because I’m human, but then it’s wrapped up verbally and all my own crap, all my own, all my own content, all my own rules about what people should and shouldn’t be. Like what I have done, my own stories about my experience. And I think that’s interesting because that’s kind [00:36:00] of how we see it playing out with our clients. We’re caught up in these, um, in these stories about ourselves related to these emotions. And I, and I, and I think then what can happen in the therapy room, right? If I’m a client that’s experiencing really profound shame. Is for you sitting across from me as the therapist. That’s incredibly aversive to be in the presence of, that’s incredibly uncomfortable because shame is a signal for disconnection. So we actually want to move away from that. We don’t want to, we don’t want to embrace that. Often as a, as a therapist sitting in a room with our client and pain, we want to, we want to stop the pain. We want to, we want to do whatever we can to avoid that or to kind of disengage from that, which is really problematic. Um, I, I think, I think one of the things that we talk about. And the context of our work together, and this is something we have in common a little bit with our DBT, is thinking about what we’re doing in, in the room to be open to the experiences that our clients are having. How are we actually physically positioning ourselves to, um, to embrace and facilitate whatever, [00:37:00] whatever’s happening rather than kind of punishing it and putting it on extinction or. We’re switching topics because we’re not comfortable talking about it. We actually just got a paper accepted for publication that I think speaks to this nicely and we’ll send you the link for it. But it was this qualitative study on veterans who had completed evidence-based psychotherapy for PTSD and kind of some of the barriers to talking about moral injury in the context of vet treatment and one veteran shared, um. You know, I just got the feeling in the air that my, my therapist didn’t want to talk about this with me. Like I wanted to go more into depth related to this thing, but she didn’t want to go there. So I think oftentimes we’re just conditioned to kind of, um, recoil from these experiences. And that in and of itself can be really problematic.

Jake Farnsworth: And I would even say that a lot of our, you touched on this, but if I could expand on it, even our training as psychologists, which often teaches us that shame and guilt are pathological.  major depression. Guilt is actually a sign of depression, right? [00:38:00] Um, and that, um, there was an article that called shame, toxic, right? And some other kind of, maybe some prominent, um, voices for vulnerability and the importance of that. You know, w which is good, but we often demonize shame, right? But imagine a world without shame and imagine my goal, what, what people’s conduct would be like. Um, shame is a powerful motivator, right? And it helps kind of us realize maybe when we can be better and more closely aligned with our values and act, which is the approach that Lauren and I kind of worked from with moral injury. There’s the saying that where there is values, there’s pain and there’s pain, there’s values. And so we really lean and leverage that heavily in our groups, that if you feel shame, it means that actually that you really value honor, that there’s something really important to you here and that your body or your, your mind is telling you that you crossed the line. And that’s good because that means that you can kind of adjust your behavior going forward. So it’s really hard to think about like, uh, this is a gift. But if we have shame, just like we have fear and all these other really [00:39:00] uncomfortable emotions, they serve a purpose. And we need to be able to listen to them. And you know, as psychologists maybe even back off some of our pathology pathologization of, uh, these experiences, which actually really serve really important functions for us,

Debbie Sorensen: right? We can learn from it if we pay attention to it in the right way. And if as therapists, instead of like shutting it down or trying to fix it, are open to it. Maybe something really important could happen.

Jake Farnsworth: And I think like if you think about like the micro mimicry stuff that happens, like when my client expresses shame, I’m going to start feeling shame, right? And I’m going to disengage from it. So I think a really important thing to clinician avoid it. Yeah. No clinician down and think about is like I, as Jake was saying, shame is a signal. That you actually care, that you care about relationships. So like I think for us, we’ve really focused on, okay, let’s slow down and notice what it is that’s coming up for us and use that as a signal as [00:40:00] providers to pursue our values in therapy with in the context of whatever is coming with it. Well, and one of the most powerful things that can happen, I think, is when someone does open up about something that they’ve been holding really tight inside because they’re so ashamed. But if they can. Open up to it and take a look at it and share it with somebody like that can be huge. Absolutely important. Yeah. And it’s, and it’s incredibly vulnerable. So we want to reinforce that

and not, not blame the shame. Right. But blame your voidance blame, blame, like maybe some of the rigid rules and kind of ideas that the person is maybe holding onto

Lauren Borges: blame, the verbal repertoire related to the shame.

Jake Farnsworth: Yeah. Right. It’s not the shame itself. It’s like, you know, if, if you got an infection, don’t, don’t blame the cut. Like, don’t, don’t, don’t blame like the pain you’re experiencing, like blame how you’re treating that cut and what you’re doing with it that’s preventing it from healing,

Debbie Sorensen: right? Like if you’re sitting in a room all day, totally disengaged from your life because of [00:41:00] the shame. That’s a problem.

Jake Farnsworth: Right.

Debbie Sorensen: But the fact that you have shame really just shows that you’re human. Yeah, absolutely. Yeah. You care. Yeah.

Lauren, you recently published a case example, and I’ve heard you present at conferences about this case. Um, and we can link to the publication that goes with it on our website. But I was wondering if, just as an example, cause I think examples are so helpful, could you kind of briefly walk us through the case that you. Published.

Lauren Borges: Absolutely. I actually, I’m really feel fortunate to do that because I think this gives us a really nice, um, kind of story to tell about our intervention and, and allows us to, um, identify the parts of act for moral injury in a, in a real kind of visceral way, which I think is better than us just taking apart, you know, the, the different pieces of Actimize. So, so I, I think this will be nice. Um, yeah. So I, so in the MIRECC we, um, we are often referred veterans who are incredibly suicidal cause we focus on suicide research. And, um, I the [00:42:00] opportunity to work with a service member who had multiple suicide attempts to just finish the PTSD residential program. Um, and he did a MIRECC consultation with us. And in the, in the context of that consultation, his provider really figured out like. Those consultations are set up to understand what’s driving risk for suicide. Why someone, why this individual had multiple suicide attempts, why he was kind of stuck inside of suicidal ideation, what was going on, and they figured out that the function of, um. Of him thinking about suicide and him engaging in suicidal behavior was to avoid shame, um, which was directly related to morally injurious events he experienced while deployed. So it became very clear that to target his suicidal behavior, we had to target as moral injury. Um, so then I was referred to work with him and he is morally injurious event. He, um. Uh, basically his job was to collect, um, information on high ranking members of the Taliban and, um, use that information [00:43:00] eventually to take their lives. So he was responsible or believed he was responsible for the deaths of men, women, children of, of several people. Um, and I think what’s really interesting about that morally injurious event is in the context of. Working so closely with these people. He learned just that, that they were humans and had developed relationships with them outside of just, you’re the enemy. Because unfortunately, I, unfortunately, we can’t compartmentalize like that. We shouldn’t actually. Um, and, and so he would actually describe that he developed friendships with a lot of the people that ultimately, um, he ended up being responsible for their deaths, which is just like incredibly. Um, emotionally complex to have, have all of those things happening at the same time. And he said, I’m kind of his primary, like, uh, motivation for treatment was just based on his suffering and that he didn’t deserve to be loved because of the things that he had done. It was that visceral and so sad. Yeah. Yeah. And intense for him. Um, [00:44:00] and, and so our work together really, um, centered around. Clarifying his values first. Figuring out, now that these things you’ve experienced these things, what is it that you care about? How do we, how do we, um, how do we start to take steps towards that and what do we need to do to take steps towards that? And I think that was the biggest piece because to, to pursue what mattered to him, his relationships mattered to him. We’ll talk about spirituality in a second. Um, which I think is a particularly interesting piece of this case study and our work and act for moral injury in general. Um, but to be able to pursue relationships, to be able to like have a meaningful relationship with this kid, he’s going to be put in contact with intense shame because he took the lives of children, right? So, um, to be able to pursue what mattered to him, he had to be willing to experience emotional pain. So I think that was, um, in clarifying as values, what went kind of hand in hand with that was, was willingness to, to try something different. Willingness to let go of, um, getting caught up in suicide to let go of overworking. He [00:45:00] just. Kind of completely consumed himself and his job, um, to let go of all these things that hadn’t served him, uh, to get him closer to what he wanted. And, and so, um, we did that together and he was actually someone, I will always remember it as far as, um, uh, just a, a really meaningful guy to work with. He was, um. So, so we work towards clarifying values and then we move to how do you actually observe and hold your moral pain for what it is? How do you hold shame? And he used to be a ballroom dancer. So he generated the metaphor we talked about, well, how could you kind of ballroom dance with your shame? How could you move with it and the service of what you care about, but not let it completely move you. Right? So, so holding it and moving with it, doing a dance with his pain. And immediately after, immediately after sharing that, he was like, Oh man, I should not have shared that with you. You are going to now use this throughout treatment too much. No, but it was, um, I think it was a really nice way of like, how do you, how do you hold [00:46:00] pain for the sake of what matters? Which is I think really what the core of, of act for moral injury is. Um. He, I, I think another, another big thing that we worked on. So, um, moral pain, the way that Jake described it. Um, it can sound kind of, um, overly reductionistic. I think like our, our group’s definition of moral pain, just like shame, guilt, these beliefs you have. Um, but, but, and I think that’s actually very critical so that we know that what we’re working with, it’s, it’s critical to kind of drill down to that level. But that’s not what our minds do, right? Our minds generate these really complex relational networks that we call stories and are in our group, these stories about ourselves and other people that we become totally wrapped up in related to these morally injurious events and related to our attempts to, um. Kind of managed the shame and guilt and all of the painful experiences that we’ve had. We, we sort of, we kind of start spinning and, and create verbal rules and create stories around how I am, how the world is to kind of [00:47:00] protect ourselves, but then we get caught up in those and actually can’t move towards what we care about. Um, so a big shift for him was really in. Learning to step back from these stories he had, uh, related to his moral injury. Learning to step outside of those so that he had the agency to be able to kind of write new ones. So they had, he had the agency to live his life and in doing that, so it was really cool. We, um. We initially did a valued living questionnaire to kind of assess like what was important to him and, um, his behavior, you know, in the past week consistent with what was important to him. And he, we got to the spirituality, um, item and he was like, spirituality is absolutely not important to me. I will not be pursuing that in therapy with you. Um, which, so to me, I was like, Ooh, this is interesting.  circle this item. Absolutely, yeah. I was a very strong response and he, um, had been raised, uh, with, uh, with a very strong set of, um, kind of religious rules, I think, or, or at least what he interpreted as religious rules. [00:48:00] And, uh, that is what he believed spirituality to be. And it was cool because in the context of like, moving towards accepting shame and accepting other facets of moral pain, he. Started spontaneously engaging in spirituality and then started labeling it as spirituality. So he’s, he’s actually building new stories about what spirituality is in the context of this work, which was like, Whoa. I mean, that, that, that was, that was really where things started to shift. He said, um. He said, uh, kind of, what did he say? He was like, you know, spirituality for me now is contributing to other people. And I think what’s really interesting about that, right? So spirituality is connecting to something bigger than you. Um, it’s reconnecting to the tribe. It’s finding a tribe. So for him, spirituality was engaging with people, which I think speaks to what we were talking about, related to how shame function. So he was. Noticing shame, but then engaging with, with a community and re-establishing and connecting himself to a [00:49:00] community, which was really huge. Um, he demonstrated like, and you could read the paper to, to kind of see more about this, but he, uh, I think improved in his, um. Value, behavioral, like 40 points on the Voq is like really dramatic. The way that his life shifted because of really how he ran with this intervention and ran with engaging in bold moves. Um, which bold moves we describe as just, um, small kind of committed actions that are values consistent. Um, and I, and I think a big piece of bold moves is that to move boldly towards what you care about, you have to be willing to have the shame that comes with it. To say that I’m being spiritual. Means that I’m going to have shame while I’m engaging in spirituality, particularly for this, this individual. Um, and I, and I want to read a couple of quotes from him, if it’s okay because they think it’s awesome. I think these really highlight the impact of the intervention in a nice way better than chicken. I can describe, um, what we think our intervention does. Um, and, and so, so the service [00:50:00] members said. The intervention did not lessen the amount of pain that I feel. It did not make it so that I no longer feel pain for my morally injurious events. What it did, it made it so that I could connect better with that pain so that I could interact with that pain with more responsibility, and it helped me to identify with areas that I connect to and be able to accept that in my life. I will always feel a lot of moral pain and I’m still able to feel happiness and feel connected to other people. So this is not about not feeling pain for what you did. In fact, who are we to tell you you shouldn’t feel pain for what you did? We weren’t there. We are not moral authorities related to your experience. What this is about is willingness to, to hold that pain and March towards what matters to you. Um. I think, I think another, so kind of in line with that, I think something that was really nice, and this is the last quote I’ll share and you can, you can check out a bunch more in the case study. Um, he, so he had completed cognitive processing therapy, which takes a very different approach to moral emotions and [00:51:00] cognitions. Um, and so in, I gave him, um, uh, an a measure of treatment acceptability that we use in our trials here called the narrative evaluation of intervention interview, um, which allowed him to kind of. Just report on his experience and, and so in one of the areas, um, he said the biggest difference between act for moral injury and cognitive processing therapy is that act is focused specifically on the idea that I need to accept what has happened and not so much tried to reassign blame for it. With many other treatment modalities, it is focused on aiding victims and survivors to reassign blame and guilt for what they had been through. In my situation, I had been unable to do so because the facts of the matter are that I bear full responsibility for the deaths of many people. This treatment was very effective and helping me to develop my values so that I can feel pain without being consumed by it, and also focus on striving towards living up to my values and accept where I am now instead of comparing myself to where I was or where [00:52:00] I want to be, so I wow. Yeah. That land. Yeah.

Debbie Sorensen: That’s powerful. Yeah.

Lauren Borges: I think what’s like really, really key about that. Is, is it’s not about reassigning blame. It’s about kind of cultivating and identifying what I’m experiencing and still moving towards what I, what I care about. We’re not trying to make you not believe that, that you didn’t do something wrong. You didn’t just make it inconsistently. You’re valued.

Jake Farnsworth: It’s really, really very Lauren’s point. Um, uh, one thing we’ve started really heavily that we are not moral authorities. And sometimes when we don’t think about the ethical implications of when we tell a client that there is guilt or shame is inappropriate. Or that

Debbie Sorensen: likeyou shouldn’t feel.guilty? Yeah.

Jake Farnsworth: So going back to that is odd dichotomy. You know, we can tell them that we could be authorities on what facts are, right. We can look at statistics, um, and, and we can authoritatively state right, what the degree of danger is for a [00:53:00] situation. But there is nothing in those three letters after our name that allow us. To, um, authoritatively state what is right or wrong, right? And that’s kind of snuck under the radar in some of our professional, um, clinical wisdom that somehow we can say, well, clearly that’s, you know, wrong, that they should be feeling shame or not shame. We try to come at that with a much more egalitarian, um, kind of sensitive to diversity perspective that there’s different worldviews about what constitutes right and wrong. And that, um, you don’t necessarily have to adopt a, my, my particular views in order to move forward with your life.

Lauren Borges: Oh yes. That’s great. No, really, it’s like you’re not, there is no right answer to some of this stuff.

Jake Farnsworth: Or if there is, I don’t have it. Right. You know, I’m not the person who, yeah, no judge on that. I’m not, I’m not a moral expert. Now we would say that we are maybe moral guides that we can say we’ve seen a lot of people traveled this road and if you tell us where you [00:54:00] want to go, we might be able to help you get there. Right? So we certainly, we can’t ignore the fact that we have my kind of moral weight and kind of a role to play in their recovery and for moral injury. But that’s not the same as being the authority that tells them where they should go and what’s right or wrong for them to do. Cause that’s not, that’s not our place.

Lauren Borges: You’re the expert on you. You get to decide what your values are. I’m not going to tell you that you should value X, Y, and Z, that that’s for you to decide and figure out throughout our work together. Yeah. Yeah.

Debbie Sorensen: So this approach that you’re doing is acceptance and commitment therapy based, and I think you alluded to this for the case, but how is it different from other approaches and why might this be helpful?

Lauren Borges: Yeah, so I think that’s a great question and one we’ve, we’ve thought a lot about. I think, um. I think the main point here is that we don’t pathologize morality. We don’t pathologize moral emotions or cognitions. We don’t try to reduce guilt or shame that someone experiences. It is not about that at all. It is about cultivating [00:55:00] willingness to experience those emotions for the sake of what matters to you. Cultivating willingness to kind of. Step outside of a thought or step outside of a story, right? Not trying to change what that belief is or what that thought is. Um, and, and very consistent with an act model, kind of the more efforts, uh, that you sort of devote towards trying to change the content of an experience, the bigger that experience can actually get and the more complex that network can actually get. Um, so, so we, we very much, um. I kind of believe in that, that perspective. I think the other thing that kind of goes alongside that, and this is certainly consistent with other approaches to contextual behaviorism, um, is we’re really focused on the function of the behavior that’s happening right now. Why? Why is this behavior maintained for this person? Why is it that. When we talk about this thing, they change the subject, or they turn around and try and, and physically avoid, um, you know, something that evokes shame for them. Right? So, so we would be generating some hypotheses [00:56:00] about, about what it is that they’re doing. They’re trying to avoid. We would imagine their experiences that are reversive. Um, and, and from that kind of information in the moment, that sort of many functional analysis than we. We generate interventional strategies that are, um, better kind of faced on approaching experiences. And I think a piece that we actually haven’t touched on yet. Um, that’s really important as our intervention is group-based. Um, and, and the reason that it’s group-based is because we believe that that provides people kind of maximal opportunities for new learning. Related to moral emotions and cognitions and related to engaging with their values. Because if they’re in a room full of other veterans who have experienced morally injurious events and are and are struggling with moral injury in relation to how they’re managing guilt and shame, they’re going to learn a lot more than, than they will probably just from. You know, the, the two of us, and certainly that isn’t to say that this intervention isn’t effective individually. The case example I just described, uh, was an individual application. Um, but we believe that putting people in a social [00:57:00] context, uh, actually kind of maximizes our, our potential for, for helping them interact flexibly with moral pain, flexibly with guilt and shame. I mean, it’s a huge exposure therapy just to be talking about this in around other people. Totally. Yeah.

Jake Farnsworth: Yeah. And it also, there’s something about your ability to see someone else struggling with a similar issue. Because oftentimes, um, the people that our group will have so much more empathy for each other than they do for themselves. Right. Um, you know, I’m, I’m the worst person in this room cause syndrome. Right. Um, and, and that can be really helpful when they all say that you didn’t turn, you know, and they realize like, wait a minute, we all think this

Lauren Borges: impossible.

Jake Farnsworth: Yeah. So there’s, again, it’s really interesting, like, um, another function of pain that we haven’t talked about yet is that it really actually bonds us together. Like, think about. The people you don’t, you maybe you went to grad school with, or, um, people that you’ve like been in the trenches with and suffered through. You might not have picked those people as your best friends, right? But just by virtue of your shared suffering [00:58:00] together, you develop a bond. Right? So, so is there something about, and I’m Sebastian younger is a journalist who wrote a book called tribe, which is all about how an adversity kind of binds people together, which is an excellent, excellent book. Um. And so there, there’s something about pain that is really valuable for us and it’s even a gift if we can allow it to be right, if we can relate to it in that way. Um, I think one point I would add to the case study that Lauren brought up was it’s about the spirituality and religion ethnicity piece. Um, just like, uh. Morality is a topic that we as psychologists don’t really get a lot of training in to get ethics training, but that’s like how to not lose your license. Like that’s not, that’s not the same .

Lauren Borges: That’s not

Jake Farnsworth: the same as like, how do you deal with someone who is going through, you know, moral injury. Um, we also don’t get a ton of training in spirituality and religiosity in terms of our diversity coursework. Um, and so, um, and when people with a moral injury. Um, those are [00:59:00] often things that are impacted. And, um, it’s hard, uh, to, to approach that to say, well, you know, help me understand about your religious values. Cause sometimes those things were the things that were wounded. Like those were the things that were kind of broken or violated. And so, like, um, Lauren’s clients. Oftentimes, veterans or clients with moral injury are kind of the deep place of what’s called spiritual struggle, right? And they don’t know really what to make of it. So we have this DOE. Dual problem is providers is one hand. We have to be able to kind of competently approach spirituality as an area of diversity and also do that when someone is in the midst of a struggle with that area, right? So, um, to kind of know how to hold that while they don’t really know what they’re even holding themselves. Um, and so for that reason, you wouldn’t imagine and you’d be right that a lot of ’em chaplaincy has been very interested in the topic of moral injury as well. And I think one of the things that we really like about intervention is that someday, maybe in the future, we think that there is a, a good, um, uh, ability to kind of have a [01:00:00] more spiritually integrated approach or to even have, um, some role of chaplaincy in delivering the intervention at some point. Um, because we think that mortality and spirituality are so just deeply connected. In order to do a good job, we’re going to need to be able to approach both,

Lauren Borges: Oh, there’s some opportunity to do some really deep work. They’re bringing those two together. I think I’m one more thing related to kind of the distinction between act and maybe other approaches to trauma or moral injury, um, is, uh, well, and I think this is also consistent with other approaches to trauma and moral injury, but maybe, maybe something that we just really try to, um, kind of engage in is, is, is in the context of figuring out. How my behavior is functioning right now. Then doing your experiential exercises that map on to how that’s functioning right now, like you said, those kinds of mini emotional exposures, because then the goal isn’t, you know, necessarily what you’re doing in the room. It’s to take it into your life in a meaningful way. Um, so we focus a lot on like, how are you [01:01:00] going to engage in this. Bold move in your life while experiencing this shame, and now let’s do it. Let’s try it. The outside of session stuff is actually pretty significant, and I would, I would say kind of like a Portland

Jake Farnsworth: kind of like values and vivos like go and do this thing. Right. That is hard for you because it’s in line with your values.

Lauren Borges: Yeah. Yeah. That’s where the action happens. Well, I appreciate the work you guys are doing. I’ve learned so much from you, and I think it’s, it makes me realize that there were times when this really needs to be. Brought into therapy and we might overlook it because people aren’t talking about it. We might not be picking up on it. Everybody’s uncomfortable about it. So I think it’s just really helpful and definitely like stay tuned from us. So I don’t think I’ve, I think I’ve alluded to this earlier, but, um. One of the things that Jake and I are working on right now with the rest of our team members, um, is a three year acceptability and feasibility study. So we’re looking at, um, do veterans find act for moral injury to be [01:02:00] acceptable? Um, also do they find present-centered therapy for moral injury to be acceptable? So we developed, um, we kind of developed a new application of present centered therapies so that we can use that in a future efficacy trial. If we figure out, like one. How did veterans kind of find this? And then the second piece of it is, is this actually feasible to implement in the VA? So that’s, that’s what we’re working on right now and, and we’ll know more in a couple of years. So it’s exciting. Keep us posted. And for those who are interested in learning more, we will link to some resources on our show notes for today. Any other resources you want folks to know about. Um, yeah, I mean, I, I think, uh, I think we both have websites that, that provide lists of, of resources. So we’ll, we’ll provide links to both of those. Um, yeah.

Jake Farnsworth: Yeah. I would, um, say, um, for those interested in the military related to moral injury, there’s a couple of good, um, documentaries that people could look at. So Sebastian Junger, that’s that journalist I mentioned before. He did two documentaries. Um. [01:03:00] One is Restrepo and the other, the other is Korengal. And so if I’m, and of course we’ll have webinars and stuff, but, but he, in that, um, those, uh, documentaries, he actually is embedded with, I think an airborne, uh, platoon that’s kind of dropped off in the Korengal Valley in Afghanistan on a mountain top. Behind enemy lines and kind of built digs in outpost. And so it really, um, and there’s a lot of footage and interviews with those service members and even though they don’t, it’s not about moral injury, they don’t talk about moral injury. Um, it’s kind of woven out the interviews and their experiences. So if people are kind of interested in kind of getting a, and there’s other great documentaries as well that I’d be happy to if people want to reach out to kind of put them in touch with. But those two Restrepo and Korengal are really excellent.

Debbie Sorensen: Excellent. Well, thank you both so much. I really appreciate it.

Lauren Borges: Thank you. This was great.

Jake Farnsworth: Thank you so much.