CARING FOR THE HUMAN SPIRIT CONFERENCE 2016

1. CARING FOR THE HUMAN SPIRIT CONFERENCE 2016 HealthCare Chaplaincy Network San Diego, California April 11-13, 2016 Chaplain Jeff Lee, DMin, BCC, LMFT

2. MORAL INJURY RECONCILIATION A 3-PHASE STRATEGY BRIDGING CHAPLAINCY AND MENTAL HEALTH VA San Diego Healthcare System

3. Moral Injury Reconciliation No Future Without Forgiveness Former SA Archbishop Desmond Tutu “…the first person that forgiveness changes is the person doing the forgiving”. p. 9 Forgiveness is a Choice Robert D. Enright, PhD VA San Diego Healthcare System

4. Moral Injury Reconciliation • Welcome ! • Workshop Goal: Equip spiritual caregivers/clinicians to address Moral Injury through the Moral Injury Reconciliation (MIR) process • Timeline: 10min = MI overview 70min = MIR 3-phase construction 10min = review/questions • Poll Question: Familiarity with MI concepts? A. Somewhat B. Moderately C. Well-versed VA San Diego Healthcare System

5. Moral Injury Reconciliation Agenda Part I • Discussion / Workshop Objectives • Moral Injury (MI) and MIR Overview • Objective I Part II • R/S and Other Considerations for Treating MI • MIR Goals, Key Concepts and Foundations • Objective II Part III • Moral Injury Reconciliation (MIR) as tx of choice for MI • Objective III • Chaplain as Exemplar of Hope VA San Diego Healthcare System

6. Moral Injury Reconciliation Workshop Objectives • OBJ 1: Explain the rational for developing a religious/spiritual approach to treat moral injury (MI). • OBJ 2: Evaluate, construct and apply theoretical theological and evidenced-based treatment components while planning the 3 movements of MIR therapy. • OBJ 3: Assess, integrate and utilize a 3-phase method to attenuate MI-related dysfunctions. VA San Diego Healthcare System

7. Moral Injury Reconciliation Part I VA San Diego Healthcare System

8. Moral Injury Reconciliation Discussion - Components: • Veteran, not DoD-focused (“warrior ethos”) • MIR’s founding methodology considers the “all-volunteer” force (e.g. ‘patriotism’, citizen soldiers) vis-à-vis ‘the draft’ (not soul repair) • Initiative for Chaplains taking larger role in Veteran/family care • Religious/Spiritual (R/S) treatment of MI VA San Diego Healthcare System

9. Moral Injury Reconciliation Discussion – Mechanisms The nature of MIR is transformation. MIR facilitates • Meaning-making (of past events) • Life purpose (in present functioning) and • Hope (for future success) MIR leverages the reconciliation process for: • Forgiveness (of past transgressions) • Communication skills (in present relationships) • Altruism (for future community). VA San Diego Healthcare System

10. Moral Injury Reconciliation Discussion - Moral Injury Defined • “An act of serious transgression that leads to serious inner conflict because the experience is at odds with the core ethical and moral beliefs is called moral injury…Various acts of commission or omission may set the stage for the development of moral injury.” • MI Themes: betrayal, disproportionate violence, incidents involving civilians and within-rank violence (e.g. MST, friendly fire, etc.). (Maguen and Litz, 2012. PTSD Research Quarterly) • “Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations”. (Litz, et al., 2009) VA San Diego Healthcare System

11. Moral Injury Reconciliation Discussion - Moral Injury Defined “’Moral injury’ is a term used to describe a syndrome of shame, self-handicapping, anger, and demoralization that occurs when deeply held beliefs and expectations about moral and ethical conduct are transgressed. It is distinct from PTSD insofar as it is also not inherently fear based; rather, during war, moral injury can arise from killing, perpetration of violence, betrayals of trust in leaders, witnessing depraved behavior, or failing to prevent serious unethical acts.” (Nash, 2007. Combat stress injury: Theory, research, and management) VA San Diego Healthcare System

12. Moral Injury Reconciliation Discussion - Moral Injury Defined “…service-related spiritual disequilibrium resulting from soul wound, war affects or disintegration of how one makes sense of the world. Such injuries can be deliberately or unintentionally caused while producing unpredictable guilt-feelings, shame, mistrust, anger and associated relationship distress”. (Lee, 2015) VA San Diego Healthcare System

13. Moral Injury Reconciliation Discussion - Working Environment • VA PCT CBOC Oceanside, CA • ~ 85-90% caseload Vets dx w/ PTSD (WWII-OE/IF) • Daily work tempo: tx ~ 5 Vets, 1-hr. ea/day • Unique ind/group MI tx focus w/ est VA MIR clinics • Facilitate Spiritual Issues and Ex-POW Groups (capture as MI?) VA San Diego Healthcare System

14. Moral Injury Reconciliation Discussion - Key Points • The priority to establish HOPE • Pastoral Presence (calling, pastoral authority) • Self-care issues (caregiver’s state of spiritual wellness and overall fitness) • Establish R/S community (the ‘spiritual alliance’) • Replaces the medical model for a holistic or biopsychosocial-spiritual care model • MIR seeks 2nd order not 1st order change • MIR reconciles a person unto themselves (shame) • Assist Vets ‘making sense’ of and use ‘values’ (virtues) VA San Diego Healthcare System

15. Moral Injury Reconciliation Discussion – Assumptions • Veteran properly diagnosed (e.g. not psychotic) • Basic environmental supports and protective factors available (e.g. housing, support network) • Sober last 24-hours • R/S community (therapeutic alliance) able to be established VA San Diego Healthcare System

16. 3-Movements of Moral Injury Reconciliation ‘Here and Now’ Focused PRESENT Phase II ‘World’ Reconciled PAST Hope-Filled FUTURE Phase I ‘Self’ Phase III ‘Future’ Meaning-making System or Values (Virtue) VA San Diego Healthcare System

17. ARRESTING MORAL INJURY: MIR’S GOAL (World) ‘Here & Now’ Focused PRESENT Communications, renewed relationships Reconciled PAST Hope-Filled FUTURE (Self) (Future) Lament, forgiveness, confession and Meaning-making Altruism, hope ‘Negative Cognitive Triad’ (Beck, 1979/83) VA San Diego Healthcare System

18. Moral Injury Reconciliation Discussion – Differentiation: What MIR is Not… • ‘Moral Injury Repair’ vs. ‘Soul Repair’– MIR promotes change and suggests lifelong transformation rather than fixing, patching or repairing • MIR is a comprehensive effort to address MI • ‘Repair’ suggests a medical model/approach VA San Diego Healthcare System

19. Moral Injury Reconciliation Discussion – Differentiation: What MIR is… • MIR is a 90-min., 9-week treatment methodology that interrupts the trauma syndrome of MI. MIR is designed to not simply reduce symptoms, but transform the system through synthesis of a Veterans’ meaning-making system and values (virtues). Reconciliation stimulates spiritual symbiosis/equilibrium. • MIR also considers such features as forgiveness and encourages altruism as experiential encounters that promote a new sense of ‘self’ with a lifelong growth and spiritual formation emphasis. • MIR values and considers a Veterans’ whole-life experience and not just traumatic military episodes. VA San Diego Healthcare System

20. Moral Injury Reconciliation Discussion: What MIR is… Since MI is a ‘dimensional problem’ (not a diagnosed mental disorder) (Maguen & Litz, 2012) and moral issues are largely linked to R/S constructs, MIR focuses on the assessment/treatment of MI and examines, interrupts, and reframes compromised and dysfunctional thoughts, behaviors, feelings, and spiritual distress. Thus, the spiritual domain is the primary focus of the spiritual care professional – the Chaplain. VA San Diego Healthcare System

21. Moral Injury Reconciliation Discussion: Background • PTSD is generally diagnosed/treated using medical models shown to be clinically effective at reducing sx to create stability (1st order change) • In theory, MI generally mimics PTSD symptoms. Current tx protocols of sx reduction cannot reconcile spiritual distress. MIR posits that MI’s roots are of a spiritual origin. • Unlike medical models targeting sx, MIR views individuals from a biopsychosocial-spiritual perspective which considers the whole person while using sacred texts, theory, evidenced-based, and experiential interventions to transform the system for more true and lasting change (2nd order change) VA San Diego Healthcare System

22. Moral Injury Reconciliation OBJ 1: Explain the rational for developing a R/S approach to treat MI. Why MIR? VA San Diego Healthcare System

23. Moral Injury Reconciliation OBJ 1: Explain the rational for developing a R/S approach to treat MI. • CBT strategies (e.g. PE, CPT) are effective for PTSD, but they do not explicitly consider the unique cultural/contextual elements of military trauma, the phenomenology of combatants or the clinical issues that arise from combat and operational stressors, losses, traumas, and experiences that are morally comprising. (Gray, et al., 2012. Behavior Therapy) VA San Diego Healthcare System

24. Moral Injury Reconciliation OBJ 1: Explain the rational for developing a R/S approach to treat MI. • “…for service members suffering from traumatic loss (in addition to or instead of PTSD), exposure-based techniques need to be augmented with techniques designed explicitly to target other variants of posttraumatic and loss-related distress.” (Gray, et al., 2012. Behavior Therapy) VA San Diego Healthcare System

25. Moral Injury Reconciliation OBJ 1: Explain the rational for developing a R/S approach to treat MI. • Qualified researchers find Veterans suffer long-term affects not well captured by current conceptualization of PTSD • Clinician/research dialogue very limited… • Existing EB strategies fail to provide sufficient guidance to treat MI (Clinical Psychology Review, 2009) VA San Diego Healthcare System

26. Moral Injury Reconciliation OBJ 1: Explain the rational for developing a R/S approach to treat MI. • A 2011 Gallop poll finds that 92% believe in God. Sacred Literature can be foundational for: • Our morals (distinctions between right/wrong) are largely derived from sacred literature. • Confession, forgiveness, community and hope • Locus of our identity, belonging and self-worth • Explicit pathways for transformation • Remedies for guilt/shame VA San Diego Healthcare System

27. Moral Injury Reconciliation OBJ 1: Explain the rational for developing a MI approach to treat MI. The impact of MI is that it delivers a specific wound: • That targets the spiritual dimensions of ‘self’ • That disrupts a sense of right/wrong (e.g. betrayal) • That produces guilt/shame • That undercuts one’s sense of personhood • That violates one’s values/meaning-making system • That exacerbates other mental health disorders • That can produce treatment failures • That may lead to loss of faith/belief system • That suggest the need for ‘trust’ in counselor VA San Diego Healthcare System

28. Moral Injury Reconciliation OBJ 1: Explain the rational for developing a R/S approach to treat MI. • Women Veterans woefully underserved (stats) • R/S domain important for overall health VA San Diego Healthcare System

29. Moral Injury Reconciliation • Part I Summary • Discussion of MI, environ, TX consideration… • Overview of MIR • MIR Object I: Explain the rational for developing a R/S approach to treat MI VA San Diego Healthcare System

30. Moral Injury Reconciliation • Part II VA San Diego Healthcare System

31. Moral Injury Reconciliation Agenda Part I • Discussion • Moral Injury (MI) and MIR Overview • Objective I Part II • R/S and Other Considerations for Treating MI • MIR Goals, Key Concepts and Foundations • Objective II Part III • Moral Injury Reconciliation (MIR) as tx of choice for MI • Objective III • Chaplain as Exemplar of Hope VA San Diego Healthcare System

32. Moral Injury Reconciliation MI Treatment Considerations CBT strategies (e.g. PE, CPT) are effective for PTSD, but they do not explicitly consider the unique cultural/contextual elements of military trauma, the phenomenology of combatants or the clinical issues that arise from combat and operational stressors, losses, traumas, and experiences that are morally comprising. (Gray, et al., 2012. Behavior Therapy) VA San Diego Healthcare System

33. Moral Injury Reconciliation MI Treatment Considerations Gray et al. argue that “existing CBT may not sufficiently address the needs of war veterans because the fear conditioning and learning model does not sufficiently explain, predict or address the diverse psychic injuries of war.” (Maguen et al., 2010; Nash, 2007) VA San Diego Healthcare System

34. Moral Injury Reconciliation MI Treatment Considerations • “Complicated or prolonged grief reactions stemming from traumatic losses share some symptomatic and etiological features with PTSD, but have been shown to be distinct in a number of ways that have implication for treatment.” • “…for service members suffering from traumatic loss (in addition to or instead of PTSD), exposure-based techniques need to be augmented with techniques designed explicitly to target other variants of posttraumatic and loss-related distress.” (Gray, et al., 2012. Behavior Therapy) VA San Diego Healthcare System

35. Moral Injury Reconciliation MI Treatment Considerations • “Forgiveness is also an important mediator of outcome.” (Maguen and Litz, 2012. PTSD Research Quarterly) • “important potential mediators w/i the context of moral injury”: cognitions (Beckham et al., 1998) related to hindsight bias and wrongdoing; forgiveness of self and others assoc. w/ PTSD and depression and difficulty w/ self-forgiveness assoc. w/ anxiety. (Witvliet et al., 2004) • “Religious coping” seemed to be assoc. w/ PTSD sy, but authors cautioned this relationship should be explored in greater detail. (Maguen and Litz, 2012. PTSD Research Quarterly) • “Adaptive Disclosure” (AD intervention) VA San Diego Healthcare System

36. Moral Injury Reconciliation MI Treatment Considerations Litz, et al. (2009) offers the ff. ex. of a moral repair strategy Step 1. Connection – therapeutic alliance Step 2. Preparation and education – plan of care explicated Step 3. Modified exposure component – “stay w/ the event” Step 4. Examination and integration – recovery of ‘self’ Step 5. Benevolent moral authority dialogue - disclosure Step 6. Reparation and forgiveness – making ‘amends’ Step 7. Fostering reconnection – positive/healing relations Step 8. Planning for the long haul – vision for future VA San Diego Healthcare System

37. Moral Injury Reconciliation MIR GOALS • Express the lament (confession) • Spt Awareness/alliance (problem insight; ‘disp. story') • New sense of ‘self’ • Re-join community (family/comm skills) • “Meaning-making”; new meaning of trauma (synthesis) • ID change (How would you know?) • The forgiveness process inauguration • ID of values, virtues/meaning-making systems • Altruism and ‘other’ focused • Hopeand flourishing VA San Diego Healthcare System

38. Moral Injury Reconciliation MIR Key Concepts • Theistic underpinnings – order, structure, permanence, meaning, moral/ethical foundations: love, commitment, high ideals, and identifying/affirming the ‘good’, one’s view of self, world, future (hope) • Body, mind, spirit, and feelings – responsibility, growth, insight, synthesis (self-efficacy), Emotional Intelligence (Goleman, 2005); emotions, a holistic approach • Forgiveness, self-forgiveness and altruism (self-supvsn) • Reconciliation to form new identity, new ‘meaning’, a sense of belonging and ‘other’ focus VA San Diego Healthcare System

39. Moral Injury Reconciliation MIR Key Concepts • PTSD is generally diagnosed/treated using medical models shown to be clinically effective at reducing symptoms to create stability (1st order change). Guilt/shame, betrayal etc. are more challenging for CB-type interventions. • In theory, PTSD’s spillover (“treatment failures”) may signal the presence of MI. Current symptom reduction protocols do not generally reconcile a moral breach or spiritual distress. MIR posits that MI’s roots are of a spiritual origin • Unlike sy-focused medical models, MIR views individuals from a unique biopsychosocial-spiritual perspective that considers the whole person while using sacred texts, theory, evidenced-based, and experiential interventions to transform the system for more true and lasting change (2nd order change) VA San Diego Healthcare System

40. Moral Injury Reconciliation OBJ 2: Evaluate, construct and apply theological, theoretical and evidenced-based treatment components while planning the 3 movements of MIR therapy. Create the Spiritual Climate VA San Diego Healthcare System

41. Moral Injury Reconciliation OBJ 2: Evaluate, construct and apply theological, theoretical and evidenced-based treatment components while planning the 3 movements of MIR therapy. Phase I – Self Phase II – World Phase III - Future VA San Diego Healthcare System

42. 3-Movements of Moral Injury Reconciliation ‘Here and Now’ Focused PRESENT Phase II - ‘World’ Reconciled PAST Hope Filled FUTURE Phase I ‘Self’ Phase III ‘Future’ Meaning-making or Value System (Virtue) VA San Diego Healthcare System

43. Moral Injury Reconciliation Movement 1 – Phase I (Self) Weeks 1-4 • Establish the spiritual alliance (intros, etc. job 1) • Showing spirituality through displacement stories other media (music, shared experiences, etc.) • Demonstrate (Shawshank Redemption) • Explicate the model • Spiritual Awareness (‘who am I’, ‘what I’m feeling’, ‘what’s my lament’?) creates sense of ‘self’ • Lexicon of Spiritual Words (NCC list) label ‘feeling-state’ (use research to explain and expand) • Foundations (sleep hygiene, nutrition, activity/rec) VA San Diego Healthcare System

44. Moral Injury Reconciliation • Make Vet folders (contact info, PCL-5, etc.) • Metaphors for Phase I (Life Saver, Band Aid) • Separate ‘thoughts’ vs. ‘feelings’ VA San Diego Healthcare System

45. 3-Movements of Moral Injury Reconciliation ‘Here and Now’ Focused PRESENT Phase II - ‘World’ Reconciled PAST Hope Filled FUTURE Phase I ‘Self’ Phase III ‘Future’ Meaning-making or Value System (Virtue) VA San Diego Healthcare System

46. Moral Injury Reconciliation Movement 2 – Phase II (World) Weeks 5-7 • Psychoeducation • Communications skills training; Stress Styles (Satir, 1991) • Emotional/Social Intelligence • Forgiveness processing • Spiritual Awareness/Insight (Recognizing Transformation) • A-B-Cs (CBT) VA San Diego Healthcare System

47. Moral Injury Reconciliation Movement 3 – Phase III (Future) Weeks 8-9 • Forgiveness processing • Choices, risks and values (virtues) • Defining hope • Exercises in altruism VA San Diego Healthcare System

48. Moral Injury Reconciliation • Find major themes for self: SA/W (insight), metaphors, “lament”, sense of ‘self’, daring, Serenity Prayer, therapeutic touch, homewk • Find major themes for world: SA/W (insight), import of community, communication (W2SM), emotions, id ‘change’, “Eyes On”, therapeutic touch, Serenity Prayer, homewk. • Find major themes for future: SA/W (insight), values, therapeutic touch, Serenity Prayer, homewk. VA San Diego Healthcare System

49. Moral Injury Reconciliation https://www.youtube.com/watch?v=Bjqmg_7J53s https://www.yohttps://www.youtube.com/watch?v=Bjqmg_7J53sutube.com/watch?v=Bjqmg_7J53s VA San Diego Healthcare System

50. Moral Injury Reconciliation Part III VA San Diego Healthcare System