Moral Injury

1. Moral Injury Psychiatric Diagnosis or Diagnosis of Psychiatry’s Cultural Tragedy of Knowledge and History Arthur Kleinman Harvard University 30 September 2013 Diagnosis, Knowledge, and Culture Conference

2. Basic Books, 1988 “Experience and Its Moral Modes”, Tanner Lectures, 1999 UC Press, 1981 Free Press, 1988 UC Press, 1997 Oxford, 2006 UC Press, 2011 UC Press, 2013 University of Oslo, 30 Sep 2013

3. Medical Anthropology, Psychiatry, and Mental Health: The Core Questions What is the difference between social suffering and mental health problems (or psychiatric conditions)? And how does that difference make a difference?Or put differently, when is it useful to medicalize and when to normalize? University of Oslo, 30 Sep 2013

4. The paradox of global pharmaceuticals for psychiatric disorders (under-diagnosis and absent treatment for the poor; over-diagnosis and abuse of treatment for the middle class and well-to-do): how is it to be operationalized in theory and empirical studies? Medical Anthropology, Psychiatry, and Mental Health: The Core Questions University of Oslo, 30 Sep 2013

5. Evidence of Social Effects All countries have health gradients that show better health status, including lower mortality and morbidity, with highest socioeconomic status Those countries with greatest economic inequality have, relative to their overall economic status, the poorest health status Mental health problems occur in clusters and those clusters correlate with economic and social problems like poverty; crime; and disintegrating inner cities Depression correlates world-wide with women, with economic and political integration, and with relative powerlessness University of Oslo, 30 Sep 2013

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7. Patel, V. and Kleinman, A.: Poverty and common mental disorders in developing countries. Bulletin of the WHO 2003, 81 (8): pp: 609-615.

8. A. Kleinman and A. Becker, Eds: “Sociosomatics”. Psychosomatic Medicine, August 60(4):389-393. University of Oslo, 30 Sep 2013

9. Social Suffering Pain and suffering caused by social forces (structural violence, for example). The interpersonal experience of suffering. The contribution that society and its institutions make to the causality or worsening of social and health problems. Includes unintended consequences of social action by institutions and programs. This concept is meant to be omnibus. Instead of separating human problems into health, social, and other categories, social suffering includes them together in a single category meant to indicate that the political, economic, and medical are inseparable. University of Oslo, 30 Sep 2013

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11. SubjectivityTransformations: the Remaking of the Moral Person PositiveNegative Globalized Self Consumer Self Greater Empathy Thinned Out Critically Reflexive Normalized Global perspective Pathologized De-Moralized Non-Reflexive University of Oslo, 30 Sep 2013

12. Religious Trance: Basque Region, Spain 1930s University of Oslo, 30 Sep 2013

13. Charcot: Hysteria University of Oslo, 30 Sep 2013

14. Vexed = ka’as (Job) = fan zao (Chinese)Shaken, troubled, harassed, distressed by something outside the person.Here affect is situated in an intersubjective or transpersonal space with the collective and the moral and the emotional somehow connected together. University of Oslo, 30 Sep 2013

15. How Do Doctors Learn to See? The Making of Doctors and the Culture of Biomedicine: Social Construction, Biopower, and Dehumanization University of Oslo, 30 Sep 2013

16. Jan Steen, (1626-1679) Doctor’s Visit University of Oslo, 30 Sep 2013

17. Jan Steen, (1626-1679) The Doctor and His Patient University of Oslo, 30 Sep 2013

18. Thomas Eakins, The Clinic of Dr. Agnew, 1889 University of Oslo, 30 Sep 2013

19. Biomedical Reductionism Population Patient Organ Imaging Histology Molecular Biology University of Oslo, 30 Sep 2013

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22. Types of Medical Knowledge Research Knowledge Textbook Knowledge Clinical Knowledge Regulatory Knowledge Common Sense / Popular Knowledge University of Oslo, 30 Sep 2013

23. Types of Medical Knowledge (cont’d) Genetic/molecular Models Psychological Models Physiological Models Cultural Models Biosocial Models University of Oslo, 30 Sep 2013

24. Clinical Reality Social construction of the clinical relationship and of the clinical communication and practices that define that relationship The accompanying clinical construction of the social world Clinical Reality is distinctive for different settings of caregiving. What is specific to the clinical reality of surgery? University of Oslo, 30 Sep 2013

25. Ruth Leys Trauma: A Genealogy • The psychological consequences of warfare • “Railway spine” • Freud’s understanding of trauma and memory • Janet & dissociation • Shell shock, battle fatigue, war neurosis • Post Traumatic Stress Disorder (PTSD) University of Oslo, 30 Sep 2013

26. DSM V Diagnostic Criteria for Posttraumatic Stress Disorder (May 2013) A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1. Directly experiencing the traumatic event(s). 2. Witnessing, in person, the event(s) as it occurred to others. 3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). University of Oslo, 30 Sep 2013

27. DSM V Diagnostic Criteria for Posttraumatic Stress Disorder (May 2013), cont’d B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) University of Oslo, 30 Sep 2013

28. DSM V Diagnostic Criteria for Posttraumatic Stress Disorder (May 2013), cont’d 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). University of Oslo, 30 Sep 2013

29. DSM V Diagnostic Criteria for Posttraumatic Stress Disorder (May 2013), cont’d C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following: 1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feel- ings about or closely associated with the traumatic event(s). University of Oslo, 30 Sep 2013

30. DSM V Diagnostic Criteria for Posttraumatic Stress Disorder (May 2013), cont’d D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Inability to remember an important aspect of the traumatic event(s) (typically due to dis- sociative amnesia and not to other factors such as head injury, alcohol, or drugs). 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad," "No one can be trusted," "The world is completely dangerous," "My whole nervous system is permanently ruined"). 3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. University of Oslo, 30 Sep 2013

31. DSM V Diagnostic Criteria for Posttraumatic Stress Disorder (May 2013), cont’d 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). 5. Markedly diminished interest or participation in significant activities. 6. Feelings of detachment or estrangement from others. 7. Persistent inability to experience positive 'emotions (e.g., inability to experience happiness, satisfaction, or loving feelings). University of Oslo, 30 Sep 2013

32. DSM V Diagnostic Criteria for Posttraumatic Stress Disorder (May 2013), cont’d E. Marked alterations in arousal and reactivity associated with the traumatic event(s), be- ginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: 1. Irritable behavior and angry outbursts (with little or no provocation) typically ex- pressed as verbal or physical aggression toward people or objects. 2. Reckless or self-destructive behavior. 3. Hypervigilance. 4. Exaggerated startle response. 5. Problems with concentration. 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). University of Oslo, 30 Sep 2013

33. DSM V Diagnostic Criteria for Posttraumatic Stress Disorder (May 2013), cont’d F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. G. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning. H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. University of Oslo, 30 Sep 2013

34. DSM V Diagnostic Criteria for Posttraumatic Stress Disorder (May 2013), cont’d Specify whether: With dissociative symptoms: The individual's symptoms meet the criteria for post- traumatic stress disorder, and in addition, in response to the stressor, the individual ex- periences persistent or recurrent symptoms of either of the following: Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one's mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly). Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). Specify if:With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate). University of Oslo, 30 Sep 2013

35. What’s the difference between trauma and PTSD? • From the perspective of medical anthropology, there are certain concerns about the translation of trauma into PTSD: • Blaming the victim • Medicalization • Is there really any treatment for PTSD that isn’t already a treatment for depression and anxiety disorders? • If not, why aren’t those disease categories sufficient? University of Oslo, 30 Sep 2013

36. For example, a former decorated soldier, now decades into a successful legal career, looks back on the atrocities he committed in the Pacific War as an indelible mark not only of his own moral failings but of society’s hypocrisy in being unwilling to recognize that war is about turning ordinary men into killers. Once the transformation has occurred and violence is unleashed, society turns its back on the moral life of the perpetrator. University of Oslo, 30 Sep 2013

37. “I really hate my job now. It’s not that I mind working harder or that I have more contact with patients ‘cause I always like that…but it’s that I don’t have any time to think about anything anymore. I’ve lost, I don’t know, some kind of contemplative space that I used to have in psychiatry. It’s all management now.” Psychiatrist, aged 50, cited in Donald, ibid. University of Oslo, 30 Sep 2013

38. Issues in the Pharmacology of Remorse Can the affective (a feeling of…) be separated from the moral (state of compunction, deep regret, repentance for a sin or wrong committed)? Can we remove affect and still experience moral sates as ways of individual and collective life? Are we‘talking only of the pharmacology of the feeling (regret, repentance, sorrow, pity, compassion)? Or does the moral experience go with it? University of Oslo, 30 Sep 2013

39. Key Questions in Medical Anthropology How does culture influence the border between the normal and the abnormal? How do norms become embodied to create normality? To what extent are health and illness embodied through the forces of global political economy? What is a ‘health care system’? How do genes and local setting come together to co-construct disease? University of Oslo, 30 Sep 2013

40. What is “local biology”? “Differing accounts about biological aging are not simply the result of culturally shaped interpretations of a universal physical experience but the products … of an ongoing dialectic between biology and culture in which both are contingent” Margaret Lock, Encounters with Aging, p.xxi University of Oslo, 30 Sep 2013

41. Movement to remake PTSD into PTSI Turning Disease into Moral Injury Potential Significance:- Merton’s Unanticipated Consequences of Purposive Action (1936) Weber’s rationalization, the Iron Cage, and the tragedy of history Stigma: ? Effects Importance of War Veterans from Iraq and Afghanistan University of Oslo, 30 Sep 2013