Starting a Process of Healing and Repairing the Lifespan Impact of Moral Injury: VXRB-6422 - admin@strongstartraining.org

Participant: wordly [W] English (US)

So good evening, everybody.
For those of you who are joining us tonight, I want to thank you for joining us.
We hope that this lecture series will introduce you to New evidence based treatments and techniques and that you will continue to train and adopt such interventions for your clients.
You can find our previous lectures on Cognetics website and they will be sent to you via email.
I want to thank Leah Paskin from the Gavin File Foundation for initiating our project in Israel.
And without her all this wouldn't have happened and I want to thank Dr. Katie Dondanville from the University of Texas and the director of the Strong Star Training Initiative.
And Katie, I must say that I personally feel lucky to have met you and her generosity with her time, knowledge and efforts is allowing us to tie together and build better training infrastructures and better services in the public sector.
And I can say, you know, we meet on a weekly basis and it's really it's it's really amazing to meet such generosity.
And I also want to thank Professor Jonathan Huppert from the Hebrew University, the leader of the Israeli project to improve access to psychological therapies, and Yonatan Amster from the Ministry of Health.
Both Yonatan and Yonatan, better known here in Israel as the Yonatan's, are working very hard.
For years and with commitment to public service.
That is really inspiring.
Since October seventh, we have trained around 200 therapists in the public sector, in the military and in the police and and think we will continue to do so.
And we are also creating supervision possibilities together with Katie and with other colleagues from the US and our lectures tonight, tonight deals with moral injury in traumatic events and traumatic events.
People may fail to prevent or witness event and even perpetrate things that contradict deeply held moral beliefs and expectations.
Such event can create moral injury since October 7th, we heard many people that describe how they failed to save others or feeling guilty for for acts they did or didn't do to survive the horrific event a events people described hiding behind other dead bodies covering themselves in others blood to look dead.
We heard policemen and soldiers criticizing themselves for failing to engage and save more people during war.
Our soldiers in Gaza might also find themselves acting in ways that go against their values, and such events can create moral injury.
Bracelets is going to speak to us tonight about the moral injury.
Brett, I want to thank you for your willingness to come and share with us your knowledge.
Brett is a professor in the Department of Psychological and Brain Sciences at Boston University and a professor in the Department of Psychiatry at Boston University.
And he developed both measures and treatment for moral injury.
And this is what he's going to share with us tonight.
So I want to thank you for your willingness and I'm going to let you speak now. Good.
Well, thank you for that introduction.
it's my honor to be talking with all of you, All 85 of you.
this evening, and and I want to share that I've been in your country. I have.
My first cousin lives in Tel Aviv. I love your country.
and my heart is broken about what happened on October 7th.
and my hope is that that, what I can share with you this evening can inform your work and help you reduce suffering and help folks over over the years to come function better.
I'll be sharing with you a very unique perspective because it's really from my vantage point of working in the in the VA, working with service members and veterans for the last 35 years, through many different wars, starting with Vietnam.
so your job is to really take from what I have to offer and personalize it to your practice, to your culture.
to the types of change agents and that you may apply regularly your philosophy of treatment, etcetera.
So that's, going to be perhaps a challenge.
but the hope is that a lot of this will be useful to you.
and because there's a lot of, currently there's a lot of confusion and pet ideas about moral injury and the media among clinicians, certainly among researchers.
Part of my job today is to really impart to you kind of a state of the art, kind of paradigmatic model of moral injury.
I really want you to leave with a firm understanding of what moral injury is and what it's not.
I'd like you to expand your clinical knowledge, your case conceptualization, schemes and your toolkit to target moral injury and loss.
it's not my goal to offer a specific therapeutic approach, but I will be talking about adaptive disclosure, which is a therapy that I developed and have tested over the years, and a new variation of that. And we have some very encouraging results.
But my hope is that anything I say will will affect the way you think about your cases and your approach and what you target and why you target it.
and there are a couple specific things I want to impact to you.
one is that in the field of, you know, the field of PTSD is dominated by this idea that you cannot you have this disease or you don't. It's really a disease model.
and there are therapies that are evidence based and the hope is that you get these therapies and you're good to go and you no longer have the disease and, although most clinicians appreciate this, I think in the form of formal models of therapy, there's a lack of appreciation of the forever lower existential impact of grave trauma loss and morally injurious events that people are changed forever.
And I think we have to honor that, appreciate that and sit with that.
I would also want you to be just generally more flexible and idiographic and personalized in your approach if you aren't already.
I'd like you to consider functional change agents and functional aims in your therapy as opposed to thinking differently or doing different things in session.
I want you to think about what people can do in the lives in the world that they inhabit to heal and repair, various problems they may have have.
And I want you to consider formalizing a compassionate approach, a compassionate training approach to your work.
So that's those are my goals in my work.
I the two unique things that we target with adaptive disclosure are traumatic loss and moral injury.
And and I won't be talking a lot about loss because moral when loss entails moral emotions like anger and guilt and shame. It really is. It's not different than moral injury.
So I'll just be talking about moral injury, but I want you to appreciate that, traumatic loss can entail different phenomenology and and require different change agents.
but there is a core commonality between traumatic loss when which is going on in your country.
epidemically I'm sure.
and moral injury because loss of valued and value, valuing attachment and belonging are central to both traumatic grief and moral injury, and each pose a threat to social bonds and ways of thinking about the goodness or worthiness of the self or humanity.
So starting with this idea of moral injury, way before we publish this paper that's referenced here at the bottom in 2009, I've been thinking about what is really harmful about trauma and what's really lastingly impactful and how the threat model or the personal victimization models are can be insufficient.
And certainly the idea of moral injury is something that that would occur if you are were one like myself.
We're wondering about the the adequacy of a threat model to to PTSD.
And so in in 2009 we published, really the first sort of clinical science treatment of this idea of moral injury.
It's a term that was first generated by Jonathan Shay in a book about, the Homer's Iliad and, and, Jonathan was a clinician in a VA clinic treating, Vietnam veterans who were very impaired, very symptomatic and tried to draw general general sort of, ways of thinking about trauma from that experience.
And Homer's work.
But in zero nine we sort of brought the desire was to bring science to bear on a problem.
And to try to think about operationally defining it and treating it.
So the assumption is that there are events that can cause a crisis of conscience and trust and lead to lasting harm. And moral injury.
Is the life altering Multisystemic impact of doing things or failing to do things or being the victim of or bearing witness to acts that transgress less deeply held moral beliefs and expectations.
And you'll notice here that we we didn't formalize the outcome.
We really talked about some general problems that may arise from these very unique life life events and transgressions since then, we have defined a syndrome which I'll be sharing with you in a moment.
it's important to appreciate that moral injury is different than PTSD.
It's not just PTSD.
principally because it does not require a criterion event, but certainly you can't have a clinical problem of moral injury or traumatic loss for that matter, unless the experience is haunting.
And the hauntedness of of these experiences is overlaps with PTSD, needless to say.
And and people will are motivated to avoid thinking and and having feelings related to the experience.
So there's overlap with PTSD. Most assuredly.
There's also overlap with depression.
you would expect people who have transgressed or who've been who've borne witness to grave inhumanity to be dysphoric and, and, and hedonic.
the reality is that PTSD and depression overlap themselves.
these are very nonspecific disorders in the psychiatric nosology the other thing is that there are unique symptoms not captured by PTSD and depression, which I'll share with you in a moment. Okay.
Well, the moment has come.
So starting about six years ago, I directed a consortium, of international partners, Israel being one of them.
Canada, Australia, UK.
and the United States.
And we went about the task of, well, the, the aim of the project.
This international project was to, to generate a measure of the outcome of moral injury.
But we, the way we went about about it is to, to examine phenomenology of service members and veterans in each of these countries.
So Israel is certainly represented here, as well as we did qualitative interviews with the clinicians in each of these countries who were treating service members and veterans to get their ideas of what they were observing.
And so this literally took many years.
We did these qualitative interviews.
If you think about the scope of it, it was pretty enormous.
And we analyzed the data and we came up with, reliable domains of impact, which in my mind define the syndrome of moral injury.
So these are necessary elements of moral injury, and I'll read these to you.
So moral injury entails alterations in self and other perceptions in which more specifically refers to disruptions in how individuals define themselves or the world with respect to what they or others are capable of in terms of transgression, alterations in moral thinking, changes in moral thinking, which entails judging the self or others.
Moralistically and with condemnation which may extend into more enduring traits of grievance and embitterment, social impacts are profound.
It's the alterations in degree of comfort with others.
Connectedness, social acceptance, belonging and changes in the frequency and quality of engaging with others.
You can't have moral injury without predominant moral emotions and moods, and the moral emotions are anger, shame, guilt and disgust.
There's also self harming and self sabotaging that that we have we confirmed in the research.
So this entails deliberate or non deliberate behaviors that negatively impact functioning and impair health, personal safety and quality of life and overall well-being.
And there's we also found that there people reported that they had changes in beliefs about life, meaning and purpose.
Some of this entails a loss of faith.
and a rejection of, faith and faith communities.
Or this could entail, deficits in broad spiritual dimensions of humanity.
So, so these domains of impact make up the syndrome of moral injury from, from these operational definitions we generated a measure which is public domain.
I'm happy to give it to you.
Someone would need to translate it to, Hebrew.
so we have the moral injury outcome scale.
In fact, well, this must have already been translated into Hebrew because I have two colleagues here.
Levy, Belz and Zirak. I don't know what university they're at.
It doesn't occur to me right now, but I'm sure I could get you a Hebrew copy of this.
Or they could provide it. So moral injury, outcome scale.
It has 14 items, so it's not long.
And, there are two subscales to the, the, we call it the meios.
And these are important to appreciate because broadly defined, there are two sort of potentially morally injurious experiences.
One, one is, someone raised their hand. What am I supposed to do?
When you raise your hand, You're going to ask a question.
Danny, did you have a question? Maybe not.
Someone raised their hand. Am I supposed to do something?
They can ask the question in the chat. okay.
Gotcha. Okay.
so broadly defined in the universe of of awful moral violations that can occur in humanity, there are two varieties.
One one is things that people do or fail to do these are personal experiences, self related events and then there are the experiences that are people are bear witness to grave inhumanity, or they are betrayed by leaders or people that should be taking care of them.
So and and or they are direct victims of others, grave violations of trust.
And these the outcomes from these two broad transgress of experiences are shame.
We call them shame related or self related events, and then trust violation related experiences.
So the TVR on this screen are trust violation related symptoms and SR means shame related.
And so there are seven trust violation related symptoms and seven shame related symptoms.
The goal here, in clinical care is to determine the degree of symptoms and, we don't have a case definition right now.
but clearly, or it should be clear that if there is some preponderance of symptoms endorsed as either agree or strongly agree, it would be worthwhile to explore the prominence of this kind of problem as a targetable issue in psychotherapy.
And I'll say that in the mouse also has a set of seven additional questions that ask about the functional impact of these specific moral injury symptoms.
So that's a second tier of of useful information that you could derive from the scale in terms of clinical care, what is the symptom burden and then what is the functional impact?
The way I define or well, guess what I should say is that the our working understanding of of any definition of a case, which I'm currently working on in, in a large scale epidemiological study, we're doing in the States, is that symptom burden is not enough to define a clinical case.
There has to be symptom burden coupled with functional problems. And it's those functional problems that we have.
We target in our in the therapy that I'll be describing for you with you in a moment.
Okay.
So it's important to appreciate that.
and there's a lot of fuzziness in the, in various s groups about the idea of moral injury.
And this is one of the fuzziest, and most confused aspects, the best way to construe moral injury at this point in our science is that it's the outcome from a specific episodic experience that is haunting currently and the symptoms that it result and the functional outcomes that result.
So not a life span, not a complex, you know, series of traumas and moral harms is what is a specific what is the specific thing that is most currently distressing for a person?
And what is its impact in terms of that kind of frame specific experiences have a range of impacts. It's really on a continuum.
So there are there are moral challenges that may lead to moral frustration that are that basically defines the human condition. These are ever present in our lives.
You can't be a human being without having some moral challenges.
a good example of this is sort of for me is climate change global warming warming.
It's maddening that there that governments aren't doing enough, etcetera.
And this is an ever present sort of moral challenge.
And I am frustrated by it.
And I think about it, often, but don't lose sleep over it.
I don't have any significant moral injury symptoms and no functional impairment.
Then there are moral stressors that are more acute, they're more self-referential.
These are things that happen to us or things that we do, and they could lead to moral distress, which if you appreciate this slide, gets you into more of an orange zone, if you will, in terms of symptoms and potential functional impairment.
But the prevalence of the problem goes down.
People who have moral distress, it's it's less prevalent.
It's, less likely to be part of the human condition.
It's more of an acute distress. Yes.
And, potential early clinical, a potential clinical problem.
And, so I would imagine that in your country there isn't a citizen that doesn't have moral distress right now in light of what happened on October 7th, in light of the challenges in Gaza. ET cetera.
and the question for clinical science is the degree to which early moral distress can trigger prevention so that it doesn't lead to the clinical problem of moral injury.
And again, I consider moral injury a clinical problem, and that's where that's how it's distinguishable from a moral distress.
And moral frustration.
And it's far less significant in the population and far less prevalent and leads to far graver symptom burden and impairment.
And our challenge is really identifying it and developing a treatment treatment plan around it.
But this is important for you to appreciate that the the way that moral injury is distinguishable from other types of moral experiences in life is that it's a potential clinical problem.
It's impairing and and people are haunted and consume by this.
The memory of what took place, not unlike the difference between stress and traumatic stress in that way. Okay.
Yet yet the reality is that that there are life span cumulative awful things and moral conflicts that happen in life.
And I want to just acknowledge the how important these are and the reality of these, what I call moral scars in, in clinical care. It's not that we could ignore them.
and, you know, repeated high stakes moral, injuries over the lifespan is profoundly corrosive and can lead to enduring traits.
It sort of goes from a clinical, a kind of a clinical syndrome to more of a personal logical impact where grievance and embitterment, for example, will become trait like, any kind of low self esteem and shame detachment becomes it leads to greater alienation and sort of a cross situational, kind of withdrawal and these things are far more impactful for our government s, society world, the world public affairs.
I just want to, I just want to note this, as distinguishable from this sort of singular, episodic way of construing moral injury.
So moral scars are present. Okay?
So shifting gears, I want to share with you a, a secular biological model of morality, because this this is, this, provides, provides the context from which a good deal of what I'm going to offer in terms of psychotherapeutic strategies come from so the first thing to say is that moral emotions are hardwired wired to support what is known as reciprocal altruism, otherwise known as the Golden Rule.
It's it's this expectation that if I take care of you and I do good things for you, you will do the same for me.
And, and that others will do the right thing because they it helps their survival to expect that, a reciprocity in that regard.
Otherwise there would be chaos and shame is triggered by personal violations of expectations of reciprocal altruism.
Danny mentioned the a potential problem of of shame and guilt from acts of omission, not being able to take care of people who, who, were under threat on October 7th not being present.
that's a that's a personal violation of expectations of reciprocal altruism and honor is triggered by others violations of expectations of reciprocal altruism when others treat us badly, that violates the sort of contract of the golden rule.
And it creates frustration and anger.
These things are hardwired.
They they occur very early on in development.
There are cross-cultural and universal in-group or US group cooperation and help is rewarding obedience, conformity, generosity and virtuous behavior is are rewarding our brain, our our pleasure centers in our brain light up when we are empathic and caretaker thing and and conform to the rules of of co operation within our US group.
It makes us feel good to do virtuous things among our US group, people that we trust and can count on for safety and comfort.
So that among those the US group, there's empathy and compassion.
And this generally creates, you know, we're kinship animals, we're pack animals, if you will, and it creates a sense of safety and comfort to have an US group that you can bank on.
but it's important to note that these virtuous behaviors that happen in US group members, they're rewarding.
By contrast, people tend to shun, dehumanize and fail to cooperate and empathize with non in-group members or them
So violators of us promoting behavior is experienced stress, fear, the loss of standing, social exclusion and shunning the the violation experience leads people to ostensibly become a them after excuse me feeling long fully part of and us and this is this is one of the worst human experiences any kind of social exclusion and shunning that happens in in a group that's important to a person's well-being and identity is terribly aversive and painful.
So, in terms of more specifics about moral injury, in terms of actions taken by a person that are transgressive or the failure to act so self-related moral injury, the US group is basically saying either explicitly or tacitly, you can no longer be one of us, and that is not even necessary by virtue of the way this works biologically, this is internalized as I can no longer be one of us.
If people cannot count on others to value them and people feel unvalued, there's a loss of pride, meaning, purpose and belonging, which are sort of the core.
this the sort of core dynamic of moral injury in terms of other related harms, moral harms, formal, reliable US groups, or sometimes just humanity, thoughts or harms a member.
This alters the capacity for social connections to be rewarding and the capacity to value others.
It affects safety, belonging and identity and it also creates risks for shameless and righteous, dehumanizing of the other.
So how does this play out clinically?
So, when when you have before I speak to the ill effects, let me, let me reiterate some of the things that thematically should should come up for you in light of what I just described.
So there are, so many things that are condoned, passive to well-being and, and positive identity and belonging that happen in our lives and when these things are working well, we have a sense of kinship, sense of belonging, which is so important.
And we have pride in ourselves, in other others and, and there are banking, bankable, caring, trusting relationships in various facets of our lives.
And we have the sense that that we can do good and feel good about it.
And we can expect and receive good.
And these things happen by virtue of three different types of attachments.
One is a kindred attachment to someone or something.
You share a common identity with family, for example.
a unit in the military, your colleagues.
Then there are valued attachment to attachments to someone or something you admire or look up to and want to honor and emulate.
And there are valuing, valuing attachments to someone or something who acknowledges honors and admires you.
When you have all these three things going on, they're really they're really the sustaining, elements of humanity and comfort in the world and, and a sense of belonging and, and, and quality of life.
Moral injury has the potential to damage all these things.
And clinically, the job is, is the challenge is to repair these attachments and to do things in the world and to recreate ostensibly value in these different types of ways of thinking about value.
So I'll switch gears and I'll talk about the original adaptive disclosure model and the book that came that we generated from the original therapy is, it's below on this slide.
And, so, so the foundational assumptions of this different, different psychotherapy for at the time, PTSD is that for serious moral transgressions reassure inference can't negate or invalidate troubling and painful moral truths.
Reassurance is the thing that we are likely to spontaneously do with people that try to, help people will have less strong feelings, days or severe thoughts about something that they did or something that others did to them.
It's quite a natural sort of interpersonal phenomenon.
But reassurance doesn't produce lasting help up.
The risk in psychotherapy is that we provide reassurance and that can be non therapeutic and hopefully it will make sense to you why and as I described this therapy, another foundational assumption is that blame worthiness is real in many cases, and this reality is the only proper starting place for change.
This entails self-blame and other blame.
so this is in a sense a moral absolutism, as opposed to a moral relativism.
If someone comes to therapy saying that they blame themselves for, a loss that occurred and they feel grave guilt about it was what we would argue is that your job is to accept that phenomenology and allow the person to for it to be honored, however painful.
And it's the starting place for, a plan of action for healing and repair or moral repair involves acceptance of these painful moral truths and exposure to corrective life experiences.
As and these corrective life experiences is are what adaptive disclosure tries to accomplish or promote.
And, and, adaptive disclosure originally came from my idea that the existing therapies ignore the social imperatives stemming from violations of us versus them rules and the lasting existential impacts.
Okay. Okay.
Some more things about the background, because it may differ from your understanding of other cognitive behavioral therapies for PTSD or loss or moral injury.
in adaptive disclosure, the what really brought me to this work was this at the time there was this expectation that if, if you had some piece of research or a clinical trial in a given context, that somehow it would generalize to other contexts.
So and at the time, the clinical trials were with women, sexual assault survivors, and the desire was to make that evidence generalizable to service members and veterans who were in combat.
And see that as highly problematic.
So I don't believe in in the equipotentiality of traumas and traumatic contexts that traumas and traumatic contexts are always different.
It you we can't generalize from a holocaust to a child soldier in some African country to a sexual assault survivor.
et cetera. Or and especially combat.
So culture matters. Context matters.
And we need culture valid change agents to target various types of traumas and needless to say that, you work in a very we at a very unique time in your nation's history, in a in a very unique context in, in the context of an ongoing war.
For that all would need to be taken into account. I'm sure you do.
an and to the extent that any of you help people who are in the IDF, there's needless to say, unique. There's a unique culture.
The warrior ethos.
the IDF is the, the doctrine is highly moral and, in most modern militaries are, the training is very moral.
but there are unparalleled role demands in the context of combat and potential indigenous sources of healing and repair, which is really the thing that led me to, to moral injury.
I'm sorry to adapt to disclosure because cause at, at the time we were working in the Marine Corps and we wanted to, we were forced really by a learning about the culture of the Marine Corps in the United States to learn how important the unit is and leadership is to helping these service members heal from trauma.
So moral injury came from this idea that danger based, threat based stressors and traumas are are the kinds of experiences in the in the occupational context of the military, as we should expect, resilience to those things.
And it's really traumatic loss and moral injury that caused the most lasting scars and guilt and shame and sorrow and anger or any aggrievement.
These are things that thwart thoughts, motivation.
They're not distinguished extinguishable emotions in the exposure framework and culpability and responsibility.
Taking and assigning is sacrosanct. Right?
And, it's, it's, it's analogous to a parent taking responsibility for their child's safety and well-being.
You could have a child that's harmed out of state, but if that happens, you still assign yourself the responsibility for caretaking.
And, and the guilt would be real for the person if the if your loved one is harmed.
any kind of, loss of faith in one's own humanity or faith in humanity, which is existential and lasting, requires a different approach.
And adaptive disclosure is that, Okay.
Moving on, Brett Yes.
There's a question in the chat. It yeah.
What happens when therapists and clients are both with moral injuries?
well, you know, the hope is that the professional is only doing care because they're capable of doing that and that they are, capable of, of, in a sense, not acting out their own pain and, and so that's, but the, the risk of that is very high.
And so this could lead to, you know, over identification for example.
So this is where a supervision, ongoing supervision is so essential because the professional obligation would be to be aware of that, to certainly not do practice if it, if it predominates until you get your own help.
and but certainly get good supervision so that you can find ways of, you know, workarounds.
I think awareness is the best thing, but it's a great question in light of what's going on in your country, I would assume that a lot of the therapists that I'm talking to right now are former IDF, and, and so who know the reality of military service, who are in the country, a small country where this happened.
so of course that dynamic is happening where you just are.
It's so painful for yourself if, but I think this is, you know, in the trauma area, you're always going to hear stuff as a human being that's sort of, you know, heart crushing and, and soul crushing, you know?
So the challenge is to not, to not, be, so affected by that that you can't do your job.
So that did I answer that enough? Yep.
Okay. But that's a great question. I appreciate it.
So with with respect to moral injury and loss here, here are, here's the model that I would like you to consider for any kind of pain means hope, any kind of moral emotions.
It's signs of an intact conscience and self and other expectations about goodness, humanity and justice.
In my in my work, all that is needed regardless of of the event type.
And I'm talking about real grave, awful things that people can do all that is needed to establish a clinical kind of space.
This is contrition that the person feels awful about what they did and they want to be different in the world.
if the if anyone feels shame and guilt about what they did, they have an intact conscience.
And their the idea of psychopathy or sociopathy is just completely off the table.
Nobody feels bad about what they did.
If they have a personality disorder.
so pain means hope and I think that's something that you can impart to your patients, that it makes them very human and it means that they have goodness in them or, or, or, and they have a, they have an understanding that there's goodness in humanity.
Otherwise they wouldn't, you know, let's say if it's an other related moral injury, otherwise they wouldn't have, you know, wouldn't be angry.
You're only angry because you, you expect better.
generally, you should assume that if somebody come to see you, these things are repairable. It really depends.
Depends on how we define the outcome of repair. And I see that as functional.
And I'll share that in a moment.
The goal, the ultimate goal is to reclaim or rebalance goodness in light of badness.
So either faith in in your own humanity and the goodness of the self, while not ignoring that one has done bad things and can do bad things.
That's part of the human condition or or faith in humanity.
A sense that there's there is goodness in the world, although there can be grave of barbaric barbarism.
needless to say, October 7th, the clinical strategies are things that you probably would think of just if I was talking with each of you about, well, how would you help people with these problems?
You probably would think of this stuff, which is unburdening the experience, the transgression, sharing it, disclosing it, getting feedback back, having someone bear witness to it.
I don't mean in in an exposure framework per se.
And in our work, we don't even need people to do much unburdening as long as they commit to functional change.
And I'll explain why in a moment.
Exposure to corrective feedback from compassionate others.
This is the kind of thing that you would think of intuitively. Like what?
Is there someone in that is a moral authority in your life that you could talk with? Can you talk to a rabbi that you trust? ET cetera.
You know, maybe someone very wise can offer something to you.
the thing about therapists is that they do have a tendency.
We all have a tendency to send solutions and have, you know, think that we are the a good arbiters of what could be healing and repairing, and for good reason.
I mean, people come to see us, but the way I see it is that the best, context to change is in a person's life and functionally and that requires reparative or that that is where reparative learning experiences happen.
So in the original model, which we've adapted and I'm going to get to hopefully in a few seconds, for traumatic loss, really the approach is not all that different from the current evidence based therapies for prolonged grief disorder.
There's some degree of emotional processing and unearthing the meaning and implication of what happened.
And then we do real time empty chair If you know the gestalt therapy frame, conversation with the lost person and, and this, this requires a confession or a disclosure of the, the loss and its impact.
The person that you loved needs to hear how you're doing and and this dead person needs to have a voice about, what what the reaction is to hearing this self-handicapping the guilt.
I don't deserve to live a good life, etcetera.
Because if it's a love relationship, the feedback will be you. You are good.
You can do good.
I want you to live a good life and needless to say, the therapist needs to shape some of this dialog. Okay.
For moral injury in the original model it was somewhat similar, but the conversation in,
In real time, in imagination was is with a compassionate, moral authority, someone who has your back, sees goodness in you will be alarmed by bad behavior.
but compassionate and hopeful about, repairing some act, doing better, being good.
And that's the kind of feedback that we would foster and, and none of this has meaning unless it's taken into the world.
And that's where the therapy really, actively, sort of, offers homework, or, you know, creates the context from which the actual repair in the world happens.
Because without that, there is, there's no sufficient change.
We've had various iterations of adaptive disclosure over the years, I want to get to this what we call adaptive disclosure enhance that.
I've provided the manual for that which I've, which you all I think can get. There's a link.
the manual comes from a clinical trial that we did, comparing it to present centered therapy just finished.
And there are 12 90 minute sessions and we added to the original model with, adding letter writing to promote, some disclosure, some confession, sharing of current impact and generating a plan for healing and repairing.
We added compassion and mindfulness training and we systematized repair homework and that, that is, that is the most important outcome in, in the, in the therapy.
And here here are the change agents in adaptive disclosure enhanced.
I won't go over these.
I think I'll probably run out of time if I, if I talk too much about these.
They're in the manual.
I highly recommend that you think about compassion training, any kind of traumatic loss and moral injury entails a loss of compassion of self or others.
And we apply loving kindness, meditation, which is a very easy to learn and apply.
sort of, strategy or way of thinking about humanity.
and yourself in, in, in the context of people to, to open up, the idea that, you share the human condition with others who struggle to be good, who have done bad, they're doing the best they can.
and it really promotes a, a reclaiming of faith in humanity, or the faith in personal humanity.
And we have a series of letters that are written, that promote sort of emotional processing of the experience and getting feedback, which is in the manual and, and a couple of things about the compassion training aspect.
it really, I mean, we've had really great success with this, with, with really macho men and women of veterans, who took to it and got it and it, and, loving kindness, meditation.
It really, I think the thing that it does, it really, it, it chips away at otherness and it's, you know, it's important to sort of be in the world and appreciate that there are others that are a source of corrective information about humanity.
There are opportunities for people to be virtuous and to feel connected.
In a way, therapy should be a way of expanding us group connection and narrowing, otherness and loving kindness, meditation basically tries to achieve that.
there is letter writing that is specific to different types of trauma, you know, moral injury experiences or loss and, and, the letters are in the manual and, and we have found them to be helpful and none of these things except, the most important change agents in the therapy were really compassion training and a healing and repair plan, agreeing to do things slowly but surely in the world that are healing and repairing of of different types of principally moral injury.
So we didn't we weren't really, militant about doing processing or letter writing if folks didn't want to, as long as they agreed to expand their compassion and do things in the world to promote functional change and healing and repair and they did just as well.
and it sort of puts the lie to this idea that you have to do trauma focused therapy.
I mean, one of the things that underscores the reality that you don't have to do trauma focused therapy is that present centered therapy is, is, is psychotherapy for PTSD.
That doesn't target trauma.
And it's very hard to beat in clinical trials.
So we did this randomized controlled trial and the primary outcomes were functioning and PTSD and externalizing, symptoms and for enhanced led to greater changes in functioning PTSD and psychological aggression.
And 21% more case cases made clinically significant change.
So we had very positive results. I couldn't be more excited.
so that's why I sort of proudly offer the, manual to you.
As you can tell, I'm rushing through some of this because I want to I want to get to your questions.
so there are a couple more slides, and I just want to, I want to so I've kind of focused in a bit on adaptive disclosure, but you have to read the manual if you want to consider those change agents.
Now, I want to sort of zoom out and talk to you about the lessons that I've learned doing this work that might help you in your work.
and I've supervised every case of Add since we started.
and there are a couple of things I'll point out here.
it's enormously difficult to heal and repair broken trust, bearing witness to inhumanity and being the victim of others bad acts.
it's far easier for people who have transgressed to take responsibility for their healing and repair.
They know they've done bad.
They know they have to do repair that in the world.
They know they have to give back.
They know that they need to be an agent of their healing and repair plan.
When you're angry and bitter and aggrieved and basically you're a victim of others inhumanity, it's it's difficult built and requires a considerable amount of therapeutic skill to help somebody become the agent of their healing and repair because they're externalizing.
They think, well, I got screwed or this happened, or people suck at and they're awful and they're evil.
So that is a challenging clinical problem.
in general, all the therapists I've trained over the years, they find it hard to acknowledge and sit with the existential realities of moral harms.
I would suggest that you think about that for yourself.
It's very difficult to do, because we are in the sort of helping business, the change business, but it is important and maybe this is somewhat related to the question about what if you're harmed yourself?
It's important to give people the space and time to have their reality of how harm they are and how awful it is, because that's a that's a forever reality. In my view.
The existing cognitive behavioral therapies address moral injury with what I would what I have called a yes but strategy.
It's didactic, it's persuasive.
I think the optimal stance should be yes and not.
But yes and unequivocally yes.
And awfully yes.
and then the challenge is and, and and now what not.
But. Okay.
Moving right along.
I think there's only one more.
Okay, so expanding out even more, there are some things I want to offer you.
Regardless of the type of therapy you do, regardless of your clinical context, to approach moral injury.
one is that I, I recommend that you conceptually conceptualize the harm.
What type of harm, what is the experience?
They're all very unique and its impact.
I would recommend using the Meios to assess symptom burden and impairment I think will help you in in your decision about whether it's a targetable, pressing problem or not.
I would assess history of and opportunities for doing valued in kindred things and having a sense of belonging and kinship and being valued.
This is super important because that's where the money is. That's where the change can happen.
Doing things that reestablish kindred attachments, sense of of value, of belonging, of looking up to people, being part of something that's important, that, and valued.
Typically people have a history of that.
We've had plenty of veterans in our trials who, who did not.
and that's a separate challenge.
The other thing is that people, can lead impoverished lives and they have little opportunity.
It doesn't mean that these opportunities can't are not available. they typically are.
It just takes a lot of work.
The goal is for you and your work regardless of the change agents you use, is to restore faith in personal or collective humanity and to identify and create opportunities for people to do things not think about things differently or feel a certain way, but to do things that are corrective with respect to good relative to bad beliefs and promoting action that shifts the balance of good and bad.
And remember, virtuous behaviors are rewarding.
They're reinforcing.
okay, so. So do one more slide.
so that's yeah, so there's the manual on there. Yeah.
So I'll, I'll stop there, and hopefully take some questions.
Danny, hi.
Okay. Okay.
We have several questions and actually I will ask them in, not in the order that they were placed, but somebody asked and I want to ask if that's okay.
He described the clinical example and if you could, you know, address how would you work with such a a client.
It's a it's a pilot who bombed the house of a Hamas fighter in Gaza and later on learned that in addition to the Hamas terrorists, he killed the whole family, the wife and children.
And, you know, these this a act or event have devastating effects on him.
And what he have done.
Yeah, that's a great example. I'm surprised this has happened.
So early on in the war that someone's presenting like that.
but that's a great example.
So the, so I would in that case I would use the mouse and, and get specific about impact and, and, and impairment because the things on the mouse are, are potentially targetable.
areas.
so you need to conceptualize the case clearly there are some assumptions that you can make, you can make going in that the person, feels that they have lost their sense of faith in their own humanity.
How could, how, could they be part of, their, in their family or in a, in their unit etcetera?
Having done this bad thing.
And I what I wouldn't do is I'm personally against this idea of cognitive therapy for this kind of experience, because the, the harm is absolute.
There is no, there's no reappraising of this thing that happened.
And although you might get some traction in having a conversation about the, the degree of, how this could have been prevented with, you know, which, which shifts the responsibility.
I don't think that's going to that's going to be a good idea.
Let the person accept the responsibility for having done this.
The, the, the reality of that and this produces the moral emotion of of shame and guilt.
The question is, how can you and I recommend adaptive disclosure, enhance how can you work on the person's self-compassion and how can they regain a sense of goodness in themselves by doing things in the military and outside the military that rebalance It doesn't eliminate the the reality that as human beings, we can do bad things.
And this is a horrifically bad thing.
So that's kind of what I would recommend. And, you know, I'm thinking about.
So, for example, if we worked with CPT, we would target the, you know, the, you know, what did he know at the time of, you know, that he launched the bomb?
And you're saying this is not a direct action. Yeah.
I would take he people are trained to to save the life of innocents and as human beings it's it's an immutable moral reality that, these are more moral absolutes, not to murder the innocent and, sometimes I'm not saying you if you can make some traction with this sort of reappraisal thing, that's fine.
but what I'm saying is that it's an immutable reality that this happened and that it it for the person and any of us.
It has a moral implication about the self that the self is capable of grave harm and in this context that happened.
The question is, creating experiences in the person's life that reclaim goodness and, and and compassion for the self and, and ultimately others as well.
So I would say by doing the corrective experiences by is by doing not re reappraising the moment that the the trigger was pulled. That's kind of my that's what I'm trying to share with you.
That's different today.
So can you give us an example to how that would look?
So so for example, if this pilot, you know, he's back home and he you know, again, I'm assuming because Yeah.
Would need to talk to the person but yeah but let's say that he's back home and you know, he's finding it hard to be with his friends to the unit and you know, when he sees his children, he's reminded of the terrible harm that he caused and the fact that he killed innocent children and and people that were in the house. Yes.
So if this if the person is in psychotherapy, I would start with the unburdening of this experience and having someone bear witness to it.
I would go through the adaptive disclosure steps.
I the letter writing may be a useful thing here to write a letter to the people who were lost and kind of emotionally processed the thing that happened.
And, and get feedback, from various sources that are, that are sort of good in the person's life about a healing and repair plan.
And this, this could be, you know, who knows what it is.
It could be if they're religious, their rabbi, it could be friends, it could be, an uncle.
But to create a sort of corrective plan of action is really what I'm saying.
A So that would be like in a way not necessarily religious, but like repentance.
Well, it's I don't put a religious frame on it at all.
Right, but, but it is, yeah, I mean, that's, it's, it's like, are there corrective good things that counteract this experience, but not in a 1 to 1 thing.
It's about restoring the confidence and in the goodness of the self while holding the reality that that the bad thing happened because that's going to be present anyway.
It's a forever memory that this thing happened and that the person did it.
So but yes, I think you could repair by doing symbolic or real things in the world.
I mean, that's sort of the the Talmudic solution probably, which is sort of like doing things that are reparative, in some way.
So, so yes, but it all depends on the individual and their context.
So, yeah, so I think what I'm offering here is I think we're too quick to think about, well, is there some relativistic way you could see what happened?
Like, is it really your fault you had a job to do?
You pulled the trigger? I don't know.
People have responsibility and it's it's not going to eradicate the moral import of what happened.
It may I'm just saying, if it's the sole solution and it's the the the the sole tool that you have, I think that's problematic.
It also it elevates the therapist to being this sort of wise sort of sage that can enter into a conversation about the, the moral relativism relativism of what happened. Okay. There are several more questions.
So one question is, would you recommend these strategies during the acute phase?
Because we are dealing in an ongoing situation because we are currently dealing with a situation that is ongoing and, you know, people who are coming in and out of Gaza and fighting or people who dealt with this.
So so, you know, when you say is a good timing, I wouldn't know.
There are other things that I would recommend.
you know, you know, psychological first aid or, I've been working in the military a lot of years.
I think we need to appreciate that the most important source of, of stress reduction and, and reduction in, in sort of conflict, that inner conflict that someone may experience is in the unit.
So and with leadership.
And so it's in the context of that where the person should be seeking, you know, they should be unburdening, they should be getting feedback, they should be doing, wellness things and working out or playing playful things.
A lot of things should happen in the unit and, and with leadership.
So, no, this is, this is psychotherapy requires, really ongoing safety really.
and and not acute potential for harm. Okay.
And there's another question and want to see maybe I can maybe expand it.
How does one heal if the perpetrator doesn't show recognition of the hurt and harm they caused? And I want to add to it.
You know, I think many of us were exposed to a really cruelty, human cruelty, barbarism that is really hard to imagine.
You know, I can say if you talk to me on on October 6th, some of the things that really I think in a way it's different, but in a way, like before September 11th, you couldn't imagine an event like September 11 even if you wanted to.
And I think, you know, many people, the values that they hold, I think many people in the kibbutzim, you know, the values that they hold, they're you know, they're some of them not all of them, but some people are, you know, left wing, you know, they're into collectivism and we're very pro Arabs and Jews relationships. Yeah.
And we were exposed to something that is really out of the ordinary.
I think in normal times, evil. Yeah. Yeah.
well, the question sort of presupposes that in order for someone, over time to heal and repair, they need the other to, to be contrite, which will never happen in this context.
So the, the challenge is how can you regain a sense of faith in humanity and connection to us groups and to feel comfort in the world when there is such the the potential for such grave inhumanity, like the worst of the worst.
this this is the challenge of, of really most traumatic contexts that are interpersonal.
and you rarely get kind of a truth and reconciliation kind of context where the perpetrator is like willing to say, yeah, I did that and yes, I killed your husband, but I and I know I'm in prison, but I want to help you or I want to I want you to know that, I mean, it's very rare. So that's the challenge.
And that's what psychotherapy is in part.
that's where it's sort of needed.
But it is, as I said, this is the, this is the biggest challenge in our, in our care models is to help people who have been, so gravely violated in their expectations of humanity and have experienced the worst of human that human beings, the worst barbarism possible.
Well, worst how how do you help someone heal and repair that?
I would not agree with the assumption that maybe I don't think that's probably not implicit in the question, but I'll just say it anyway.
Contrition is not going to happen.
Your enemy is never going to appreciate your humanity, your humanity, and not treat you like a them and dehumanize you so that's where you have to find and goodness in your community.
but forever, I mean, how can you not, Danny, appreciate forever the rest of your life the possibility of that humanity can bring this kind of behavior.
It's never going to go away.
Yeah, it's never going to go away.
And I think, I think it's it's a real challenge for many who believe in who believed or believe in the goodness of others. Right.
But but it means if you if you have, let's say, your kibbutzim and you were like very socialist and you and very liberal and you felt like you know, your Arab neighbors, etcetera, it means that you have the capacity for goodness that you expect this from your community, be that you want to do good.
You don't want to dehumanize others.
It means that you have in you the sort of schemas, the inner mechanics to apply that.
Again, it's not that's not lost. Yeah.
and, and so one needs to create the goodness communities over again.
But the, the reality about the what we would call easy easily evil, is an enforcement part of humanity since time, you know, since the, since the cavemen came out of the cave, you know
there's a question, there's another question.
This is not sounding hopeless.
It's not my intent.
It's just, you know, I, you know, I can say challenge.
These are our challenges. I can say personally, I think it's a challenge.
But, you know, we have to remember, you know, I think that the alongside the terrible things that we saw on October 7th, we saw amazing things that, you know, Bedouin and Muslim people did to save Jews and to to help people.
And, you know, I think therapists have to hold this in mind and keep it in mind, you know, to help balance their own beliefs.
And I think there's, there's a many, many stories like this that of since October 7th and in October 7th that. Yeah, yeah.
Well I, I harken back to the original question because now I can better appreciate the possibility that a therapist can be so angry and so bitter and so dark in their beliefs by virtue of maybe being there or what they experience or some loss that that it that it's hard, hard to think for themselves as regaining a belief about the goodness of others.
and might these things might ring false to to help someone shape a plan to, you know use compassion and other resources to regain a faith in humanity.
I mean, I understand the conflict put it that way.
I understand the conflict.
And, bitterness and aggrievement and externalizing are the most dangerous things for psychotherapy to be there.
Just just, just make it so difficult.
But not impossible
Any other questions on on there's another question about, you know, what the markings on asked a lot of people, you know, lost many people around them and multiple losses like death of loved ones and loss of values and their home and their community.
And, you know, is there do you address it in the model and in the interventions that you do with this model?
you know, frankly, we haven't we've dealt with, you know, acute war zone loss of a person that you loved.
And it's, it's it it coalesces around this loss.
you know, traumatic loss from violence of a person, having your family be murdered, losing your community.
The challenge is, is, is, I think to still, to think about the long haul and to not see psychotherapy as the, as somehow curative.
and at the end of the day, the model but also anyone in helping somebody has to think about community.
You know, the government and community and, and, other contexts, let's say religious or otherwise, is, this is where one can reestablish a sense of goodness and connection and feeling valued and, valued and, and, and being part of a valued us.
however painful, but the enormity of it is so profound.
I mean, I'm not sure.
I think the thing to appreciate is that like, I'm not sure that I could live in that world, you know, any of us. How do you live in that world?
You know?
And it's a question that we hear from many people who experience this.
Absolutely. Yeah.
yeah.
So I think last week there was somebody who committed suicide.
And it's not surprising at all after viewing he wasn't in the events, but he was viewing the videos in the first day that actually came out.
And the his family said that after viewing this these videos, he kept, you know, saying that how can you live in this world? It's so terrible.
It's so you know, I want to ask you, a when you're describing it, I'm thinking about clients, you know, and if you come with this, you know, with this notion, you know, how can you live in this world?
And in a way, the therapy you're describing is asking people to engage in something social.
Like, yeah, Well, sure. Yes.
And how do you address people who, you know, would say, you know, this word is so terrible, I don't want to, you know, or how do you address people?
Who are you know, find it very difficult to engage?
Because I'm sure for some people this is going to be a challenge to get back. Of course. Yeah.
I think, you know, I think you have to think about, what this world means and, and, get more specific.
Help the person get more specific about, the world that they're talking about.
I mean, it is a, it is a, an overgeneralization to think that your family or your community will be part of this world that is evil.
And I think that rather than use a cognitive therapy frame to sort of get them to sort of appreciate the distorted way of seeing the overgeneralizing, I would just help the person plan something that is highly local, highly personalized, highly specific, however hard it would be to just try on being part of a not the world, but a and, you know, an experience that is, local and doable.
So yeah, I think that that would be what I would recommend, but yeah, I think yet it's, it would be important to appreciate in a sense how dangerous the world has become for people, and how despairing and, demoralized it is to live in a world where these things can happen. no doubt.
I mean, that's, that's just the human experience of it.
There is another question about, you know, is, is, you know, you know, are you using the therapeutic relation ship in any way?
You know, for example in the pilot's example, you know, to to help the client engage or in any other way that is 100%, 100%.
I'll tell a little story that I've been doing this supervising this work in clinical trials since the start for many years now, like 20 years and the therapist that had just that, that, that spark of and that, very unique human talent of being compassion definite and press decent and comfortable with whatever they were in front of and very deeply empathic and caring, if not sort of in a secular way, loving the person they did so much better than the young therapists who came out of graduate school thinking that their job is to tinker and to do specific things and to do procedures.
You know what I'm saying? And what that sort of proves the case.
The obvious case that the humanity of of an openness of the therapist and their caring, is, is a critical it's a necessary component.
And, so, and it's inherently corrective. It's just not enough in my opinion.
But it's inherently corrective.
So 100%,
we'll stop.
There's a, there's a question that I'm thinking, how would I translate it?
But, but how would what, how would you what I'm thinking how to translate it to English.
Can you define the goal of the underlying work, cognitive work or, you know, the work that you do with the client as an attempt to prevent the a moral generalization of the event self others?
You mean?
So the the question is really a statement that the person feels like the the therapeutic task is to help the person, not overgeneralize and see all of humanity as bad kind of thing. I think.
Yeah, yeah. I'm just saying.
Yes, we all want belief change.
We're all looking for belief change.
We want to rebalancing the scales of goodness and badness is about belief.
Like I'm I can be good. I've done bad, but I can be good.
And I know I can be good. And it feels good to be good.
Those are beliefs and expectations.
I'm just saying the way to get there, the most lasting and impactful way to get there is for the person with your help and your care and your compassion to do things in their world that correct those beliefs rather than ABC sheets.
And you know, some, you know, Socratic dialog.
I think that the best corrective experience is in the person's life.
That's, that's basically what I'm selling here, that belief. We're all looking for belief change.
We want to promote the, the, we don't want people to overgeneralize.
Of course the aim, the goal is to not for apropos of what you were saying, Danny, we we don't want people to think that the entire world and everybody you see on the street is evil and bad and that you can't trust anybody any and that you can't live in a world where this happens because it happened.
We want we don't want that gross overgeneralization.
I'm just saying it's a different chain.
It's sort of different spectrum of change agents than the standard sort of reappraisal framework. Does that make sense?
Yeah.
A another question in and I think that's a it's a good question.
I want to I want to before I say the question I want to say on October sixth, the headlines of one of the newspaper, Yedioth Ahronoth, which is a main one of the main newspapers in Israel, was the disaster is going to be on your hand.
You know, so that was and the question here is how do you work with people who lost faith in their leadership, in their army and, you know, I think for many people, you know, and this is we have to remember, we we have been Israel have been in a, you know, before these events.
We had nine months of protest against the government.
I'm aware. I'm aware.
You know, and actually, the people of Israel split into two parts, you know, at least half of them are, you know, regardless of left or right, but half of them are against the government and about half of them are for the government.
And I think we can see people on both sides that lost faith in government and in the military and police. Yes. Yes. Yeah.
Well, you know, in America, we're sort of expert at this stuff.
You know, I think, loss of faith in politicians as in leaders, in the military.
I mean, it's, it's not even unique to, to Vietnam.
And afterwards in our country, loss of faith and, and, embitterment, is fundamental to the social political dynamic that's happening in this country. And it's awful.
And, and, with respect to, I guess the, the, the, the violation of, protecting from harm that happened.
I suppose I can say that, in your country, how, how does is the question, like, how do you regain a trust in the government?
I guess, you know, in many of the systems you know, the lack of systems, right?
Disappointed the citizens. Yeah. And for those things, I'm not.
This was a surprise attack and.
And but a lot of the context was was very difficult. Right. No, I understand. Yeah.
You know I can give an example.
I heard there was a demonstrate in a few weeks ago and people yelled, you know, up to the policeman, Where were you a in, you know, in one in Barry or in one of the and you know, this is I think it's I don't judge the people who who yell this Yeah.
Because they screamed from their pain but a lot of cops lost their lives in this event and yes. And forth.
You know, the best they could. Yes.
I think, you know, when you're talking about this sort of macro level, I think at the end of the day, this is sort of personal opinion.
It's not science or clinical experience. Yes.
but also being a citizen of the world and a citizen of my own country, I think what is needed is a change in leadership.
corrective trust.
that's, earned and, and sort of corrective experience at the level of community, not the self, not what people do, but, but so the government has a, has some work to do, to heal and to regain trust. And that's their job.
And the way I see it, it's sort of a truth and reconciliation affair and the truth and reconciliation model is that, the, there needs to be contrition, there needs to be a ownership and responsibility taking at the highest level and even down to individuals as long as it's therapeutic for the community, for people. And the goal is to reestablish trust.
I mean, this happened after apartheid in South Africa.
So so I think, you know, I would I would apply the truth and reconciliation model, and that requires truth telling, you know, and that's hard for governments to do, especially in a time of war.
but it starts with, you're saying on a national level.
Yes, true truth telling and responsibility taking.
you know, which I guess hasn't happened enough, so but it never happens.
in the throes of, of ongoing things.
So yeah, it'll take time.
but we regained our, our trust in government after Nixon and after Vietnam and, trust in the military.
I mean, these things are somewhat cyclical, but it is certainly possible.
So hopefully that helps.
Okay.
I want to thank you for this lecture.
And I must say that you you challenge my worldviews.
And it's very interesting in terms of cognitive therapists, then, yeah, I must be a cognitive therapist then. I am. And.
But I think it's very interesting and definitely an avenue to explore.
And again, thank you for sharing with with us the manual. I'm sure that people will find it very helpful.
Thank you for your time and I'm sorry for the misunderstanding about. Okay, that's okay. All right.
And thank you all for listening.
And hopefully this would was useful.
Thank you very much