Episode 3 – Moral injury — with Fardous Hosseiny

MIND BEYOND THE MISSION EPISODE 3: “MORAL INJURY WITH FARDOUS HOSSEINY”

Laryssa

Betrayal, guilt and shame are the hallmarks of moral injury. Moral injury refers to the psychological, social, and spiritual impact of events or acts that a person performs, witnesses or fails to prevent, which conflict with their own deeply held moral beliefs and values. Attention to moral injury has grown over the past few years, and yet many Veterans and Families are unfamiliar with the term, how the injury manifests or how it differs from PTSD.

Many Veterans struggle in isolation to make sense of what they experienced. Whether intentional or otherwise, Veterans who struggle with their own darker concepts of self seem to push loved ones away. And the stark lack of information and education on moral injury available to Veterans and Families perpetuates the problem.

Brian

Sometimes Laryssa, when people talk about moral injury, to me, what I really am looking at is what’s actually bugging you about a situation. And I think there’s a number of times in my own history where people would make assumptions, i.e. “You went to this incident, it was bad on paper, therefore that’s what’s bugging you.” And that almost ticks me off more because it’s completely sometimes missing what’s actually going on with me. And so, there’s textbook definitions of everything out there, but for me, what moral injury really speaks to is, what’s the backbone of the problem here? Because it’s not always trauma, it’s often disappointment. It’s feeling isolated from this organization that promised that you’d never feel isolated.

And when I first started working here, a number of different projects were put in front of me joining the Atlas Institute. And the first one that I put my finger on, I told my boss at the time, “I want to be on this file one way or another,” it was moral injury, but it still took someone to explain to me what they meant, and I’ve been at this for a while.

So in that regard, we’re joined today by our guest Fardous Hosseiny. Fardous is the CEO of the Atlas Institute, but he has also got some background in working on the moral injury case, and so we figured what a great time to introduce you, because you got a background in the file, but you’re also the guy that’s running the Atlas Institute for Veterans and Families. So we’re talking moral injury, but you’ve got a pretty big responsibility on your lap. You’re running a new organization and it’s an important one.

Fardous

Well, yeah, thank you for having me on. And to your point, Brian, even when we first started the organization back about three years ago, pre-COVID, we had a chance to do some in person consultation. So we went out to Vancouver, we met with some Veterans and their Families, and many of them were describing something that at the time, folks thought it was PTSD, but when you broke it down a little bit more, you heard the shame, you heard the guilt, the betrayal, then we identified: that’s moral injury, that’s not PTSD. So there are discussions that moral injury is not different than PTSD, but if you actually sit down with the Veteran who describes their symptoms or what they witnessed or what they went through, they’ll tell you that’s a reality.

Brian

A common refrain when military people are asking questions about their planning is, “So what?” You know, like, “This is happening,” or “This is different” or “You need to know that.” Okay. Why? What would be different for a patient when someone hones in on the fact they have moral injury versus PTSD? Are the prescriptions different? Are the treatments different? What’s actually different about it?

Fardous

Well, moral injury’s still not recognized in the DSM, right? It’s not a diagnosis as of yet. So the fact that we’re having this conversation, our hope is with research, we can actually say that this is a diagnosis of its own. So then when you do get treatment and you get care, the clinicians are prepared to offer you supports that make more sense, that address the shame, guilt, betrayal, versus PTSD which is fear and anxiety.

So unfortunately right now, it’s still not a diagnosis, but the fact that we’re having this conversation, that we’re putting a spotlight on it, our hope and through the work of Atlas, our vision is that eventually we’ll get to a place where we have this scale where we can say, “Okay, this person is showing symptoms of moral injury, another person is showing symptoms of PTSD. Let’s run them through a brain imaging scan, and then we can actually show different areas of the brain that are lighting up.” And once we have that under our belts, then that’s when treatment options can be discussed. But yeah, we’re still unfortunately in preliminary days, many other researchers will say, no, we’re far ahead, but unfortunately we still have a ways to go to get it to a formal diagnosis.

Laryssa

That would be pretty exciting if we could get to a point to be able to separately diagnose or identify PTSD versus moral injury. Could you go in a little bit more to describe what is moral injury? I think we’ve touched on it a little bit, but could you explain to folks what is a moral injury?

Fardous

Yeah, so it starts with talking about the history, right? So moral injury, Brian and Laryssa, you’ve mentioned that it’s in the discourse now. And the fact is because healthcare workers have come out and said that they’re struggling with moral distress or moral injury because they’re put in positions to make these calls. But if you look at Dr. Jonathan Shay, a clinical psychologist, back in 1994, he coined the term “moral injury.” And that’s because he saw a lot of Vietnam War Veterans coming back and describing their symptoms and he’s like, “This is not PTSD.” So he’s the one who coined the term “moral injury.” And as a result, as of right now, you talk about looking at the literature, there’s actually 17 different definitions of moral injury, all with slight variations, right? So Shay talked about authority, someone betrayed by someone who has an authoritative position, you feel institutional betrayal. You feel like someone who has put you in a position where you have to make a call, but you’re not equipped to make that call… so Shay started that.

Then it built to other psychologists and other researchers. And recently Dr. Brett Litz, who’s out of Boston University and who we’ve been working with on a moral injury outcome scale, he’s actually kind of the pioneer. And he has the most recent definition, which is, “the psychological, spiritual, and biological consequences of facing or seeing something that violates your moral beliefs.” And then we can talk about potentially morally injurious events. Those are transgressions. Either you conduct a transgression yourself, or you witness a transgression. So that’s the current definition of moral injury.

Brian

For me, it was a new term. You speak of the first kind of light bulb in the community going off in 1994… that light bulb didn’t go off for me until about five years ago, which was the first time I’d really heard of it. What I do know is that quite often in our world, it’s actually our spouses that are the first person to put up their hand and go, “Something’s going on here, something’s being missed.” What did you hear when you first heard the term? Like, did it make sense on its own or did you need to hear a little bit more to it?

Laryssa

I think I wanted to hear a little bit more to it because it validated it for me. I have a background in peer support, for 15 years, so I was very familiar with the term post-traumatic stress disorder, PTSD. My spouse was diagnosed with PTSD and so I was familiar with the behaviours, the symptoms. We developed strategies. I developed strategies on how to support him, but I found that sometimes those strategies didn’t work. I found there were different kind of things occurring. So I knew that withdrawal was a cluster of symptoms of PTSD. I knew that hypervigilance was a cluster of symptoms, but those weren’t the things that were keeping my husband up at night.

And so, once I was introduced to the term “moral injury,” I was like, “Wait a minute here.” I wanted to learn more and pieces started to fall into place for me. It was more about the sense of guilt that he had. Guilt was huge, and still is. That’s something that he has to work on, and the negative self-perceptions, I guess. So those things to me weren’t fitting for PTSD, but it made sense that he’s experienced a moral injury.

Brian

What I found kind of tough in this space was, if I’m ever talking to someone about moral injury, I undoubtedly have to say words like “I feel” or “I felt” or “it felt like.” And we’re already getting into the tricky parts of the conversation that I generally don’t want to have. It’s not easy to talk about trauma, but in a lot of ways, it makes more sense. The average person can understand when you describe a terrible event, what’s terrible about it, right? But to explain to them how you might feel abandoned… you know, “I feel,” I don’t like that all the time. Abandoned: not good. Not a good army feeling, that’s for sure. And so this is kind of what it did for me was all those things that I never really found a way to put my finger on. And it always went against what other people’s assessment was. So what I mean by that is people would look at, “You went to this event. That was bad.” But I’m actually more bothered about what I drove past on the way there, you know?

I have seen situations where I’ve watched… women being hurt is the only way I can really describe how they were being treated. But that was on the way to something else that we had a mandate to deal with. We didn’t have a mandate to deal with how women were being treated on a side street. Even if we did, we had 3000 people in a 50 million person country. You couldn’t do something if you wanted to. And so, you had to drive by. And so, it’s easier amongst a lot of people to describe what happened to me when I got where I was going, but what keeps me up at night is what I drove past. We tell people this: that what you drive by, you accept. That what you ignore, you accept. Well, I understand why I drove by it. I did the right thing. But somewhere in there, the dad, the Brian… it feels like he accepted that.

Laryssa

That feels like part of moral injury, the second guessing of your own actions or, like you said, Fardous, of someone else’s, what you’re observing. I have a couple questions. I’m wondering, can PTSD and moral injury happen at the same time? And are there differences that you can help us out with?

Fardous

Absolutely, yeah. So I think to Brian’s point, we mentioned potentially morally injurious events, right? So that’s one that violates your own core moral beliefs, or you witness something where you can’t intervene, right? You know that your moral code tells you that I should probably intervene. I could probably do something here. But the rules of conduct or rules of engagement say you can’t. So that is an experience of a potentially morally injurious event. And the second was to Laryssa’s point. You may witness someone else doing a transgression, and again, just witnessing it and not being able to engage to do something that you would do differently, again, impacts you. And you might be marked by the experience. As soon as you’re marked by the experience, that’s when it becomes a moral injury.

But yeah, to Laryssa’s point around PTSD, I think the discussion is that they’re very, very similar, unfortunately, right? So, they’re both trauma based, right? So they both start the same. But when you look at the differences – and this is where the conversation gets interesting – is you have to look at the origin of it first, okay? So PTSD, as we mentioned, is usually fear and anxiety based. Sure, there might be some shame and guilt, but for moral injury, that’s central. That’s the central symptoms of moral injury. The second is looking at attributions, right? So in PTSD, there’s more sense of horridness, helplessness. And in moral injury, someone will say that, “I actually witnessed this or I conducted this and I should be feeling bad about that.”

You know, it’s not that sense of helplessness. So you accept that, “I might actually be a bad person because I didn’t do anything.” So the attributions are very different, right. And then when you look at treatments, I think that’s also something that we have to still look at because if someone is dealing with PTSD – and prolonged exposure therapy is the gold standard for PTSD – but if someone is feeling guilty and shameful of what they do, and you tell them, “Relive that, relive that, relive that,” how helpful is that? Right? I don’t think it helps someone make sense of their situation. So there are some differences and I think that’s where the discussion needs to continue being is because we have to distinguish between the two. And once we’ve distinguished between the two, then we can look at treatment options.

Brian

Well, and one conversation we’d had before was kind of about the flash to bang or the timeframe. And we were talking specifically about the withdrawal from Afghanistan, which is, for me, a tricky situation to watch. And by that I mean it was awful, right? Watching that was not pleasant. But we spoke about how those are natural things. You’re going to be bothered by things that are bothersome. But is there a point or a timeframe down the road where if you’re still being kept up by that or it’s still impacting your relationships, if today, a full calendar year and counting later, that incident is causing large amounts of grief, do we have a ballpark of what that time is? And then what? So what? What do we do about it?

Fardous

So what you’re describing there is a bit of a continuum, right? At any given moment, you may see something, you may do something that challenges your moral codes, and if it just challenges it at the minimum level, that’s more moral frustration, right? So it’s just moral frustration. When it gets a bit more to the milder degree, then you’re dealing with moral challenges and moral distress. And then the third is when it’s more extreme and it actually violates your core moral beliefs, and as I mentioned, you’re marked by the experience, then that’s moral injury. So it is a continuum. There might be moments where something occurs that ticks you off, and that’s moral frustration, right? And then you might deal with that. You might say, okay, that’s not a big deal. You’re not marked by it. You move on, you’re onto the next thing.

But if that builds and the next time you see something and it’s even more significant, you’re like, okay, now it’s a moral challenge, it’s moral distress. And then you see, okay, now this has violated completely my core beliefs and I can’t move forward with it because I’m marked by that experience.

Brian

It’s so tough too, because you’ve got rules, you’ve got realities, they all come into play. If you take the medical circumstance, our medics in the Forces are phenomenal. They can keep people alive today that had no chance decades ago. And they can do that for anybody. And so there’s a number of circumstances where wounded would call into the base because they know that we’ve got first notch kind of care.
The capability there is incredible. It rivals an ER here in Toronto. But you can’t be the doctor of the town because if you do, tomorrow you’re going to have 10,000 people lining up outside your gate with your coughs and your sprained ankles that you can’t handle. And they have to get used to going to their own system to demand that it serves them.

So the bottom line is, in a lot of our missions, we cannot medically help people in a lot of circumstances. That feels awful for our medics, for our doctors and our nurses. They’re trained, they want to help, they’ll take any patient. But we could set off a humanitarian catastrophe in that town if we get seen as the medical experts, so we can’t. That happens.

And for me, I had a situation actually in the former Yugoslavia where we had a case where we could feed people – as in we could, we had food – but we couldn’t, because we would’ve done the exact same thing as just described. So the answer was, instead we secured the area that they were at, we did not feed them and we made them go to the aid agencies that were there to feed them.

That feels like garbage. I still am bothered by that. And when a lot of people hear that, what shocks them about it is that they expected to hear a war story. They expected to hear some big tragic tale with a huge body count – and those are out there – but what bothers me is I’m a dad. You would feed kids that are starving when you’re a dad. You look after people. I’m a good person. You would want me as your neighbour. But those don’t feel like really neighbourly ways of conducting yourself. I don’t know, does that fit? Is that moral injury? That’s I think what a lot of people in my situation are [wondering] is, is this the thing you’re talking about?

Fardous

Oh, 100%. I think you just described really well what a potentially morally injurious event is. And I think a few other examples on the battlefield is similar to what you just said, witnessing a situation where you know what the right thing is to do, you want to do the right thing, but you’re not allowed to do the right thing.

Another is using deadly force or combat, where you feel like the individual in front of you may not be the individual that deserves that or needs to take that. But you have to, again as a result of the rules of engagement, you have to do that. So, using deadly force is that. Giving orders that may result in the wrong decision, that may result in civilian deaths as a result of the call that you make, that could be moral injury. Failing to report knowledge of a situation, like saying again, you have intel on something, but again, you may not be able to share with someone and as a result, that leads to something catastrophic happening. That’s, again, a potentially morally injurious event. So these are examples of the war field where you talk about fighting and combat, but these other calls that are being made behind the scenes, these other calls where folks might think it’s not significant because you’ve gone there to do one thing, but it’s not just the only thing that you’re doing when you’re on the battlefield. There’s other decisions that you have to make on a regular basis that as a result of them, something bad can occur and then you have to live with that.

Brian

And then this plays out in the home. When someone asks me, “What’s bothering you?” or “Let’s talk” or “How’s it going?” like, do you really want to hear about when I didn’t feed kids? I don’t think I want to tell you that.

Laryssa

Yeah, I think a lot of Family members think they want to know. We’ve talked before how Families want to support each other. Families want to support the Veteran. And for spouses or significant partners in particular, we’re supposed to be the sounding board, the supporting person, right? We think we want to know, like, “Let’s talk about it. Tell me what happened, get it off your chest and I won’t judge you,” and I think we like to think that won’t happen.

I think that makes it difficult for the Veteran because what I’ve heard from some Veterans who are living with moral injuries, they can’t even look at themselves in the mirror. Fardous even talking about- I think a key that you said was decision. It sounds to me like a lot of times it comes down to a decision that a person has to make in the moment and then they’re second guessing that decision for the rest of their life with the disadvantage of having hindsight.

So later you’re going back going, “Oh, I should have, I could have, I saw… I have this information now,” and second guessing the decision that they made. And so as I was saying, a lot of Veterans are staring at themselves in the mirror, or maybe not because they can’t look at themselves trying to rectify decisions they made or maybe things that they observed.

And they don’t feel – because of that shame and guilt you talked about – they don’t feel worthy of love. They don’t even love themselves. And so what I’ve observed within Families is the Veteran, whether conscious or not, pushing their loved ones away thinking “I don’t deserve to be loved by you” and the Family member is completely not understanding what moral injury is, they may not have even heard the term before, and so they might take that personally and think it’s a reflection of the strength of the relationship, or maybe I’m not good enough to be loved. Maybe there’s something wrong with me. And so it becomes very complex just to scratch the surface on how Families are impacted by it.

Brian

And I think one thing that Veterans want to hear is that people really get the scenarios that they’ve dealt with. It doesn’t mean you’ve got to go into them all, but we often talk about things you couldn’t help, things you couldn’t do. But it goes both ways.

Sometimes I could fix this town if you would just let me take out that guy. If we could just arrest this guy that we all know is causing the problem. He’s the mastermind. He’s the bomb trainer. He’s right there. We’ll grab him. You can’t. And so you’re subjecting this town to more and more and more, and it’s done for a reason. It’s not that the people making these decisions don’t know what they’re doing, but at the coalface, where you’ve got to be the implementation tool of those decisions, it’s tough. I know from my circumstance, there were cases where you could feel that the person on the other end of the phone 10 kilometres from you, who is a military person who understands your circumstance, doesn’t understand enough to make good decisions for this.

Well then, what happens when that decision is being made in Brussels or New York or Ottawa by someone that is completely not from your background? And even if it’s not true that there’s disconnect, there is a sense of disconnect. And I found that particularly tough to stomach sometimes.

Laryssa

So can I ask you, Fardous, a little bit of what Brian is talking about, to the best that you understand, is that a moral injury that occurred someplace other than here impact a Veteran’s perception of the world here and now as they see it, their perception of people in Canada where maybe those types of events didn’t happen or we would hope wouldn’t happen? So does it change their perception of humanity or the “greater than?”

Fardous

Yeah, some of the work that we were doing with Dr. Brett Litz at Boston University was, as I mentioned, the development of the moral injury outcome scale. So to your point earlier, it’s not even events-based, it’s that outcome, the decision that was made, right. So it’s the outcome, and that’s what we’re measuring right now.

And then when we developed that scale, there were six domains that came up, that rose to the top. The first was what you just spoke to: alters in self-perception. So that’s, “I feel like I’m a bad person.” So that’s what the sense is and that’s huge. That’s at the core.

The second was around alterations of moral thinking. So, “I’ve lost faith in the goodness of others, or in the faith and the goodness of the world.” So that’s, to Brian’s point, when you come back, you may have lost faith in the folks that were making some calls in the local neighbourhood.

Don’t know your background that made decisions that you know, you don’t agree with. So, you’ve lost faith now in the goodness of others. The third is looking at social impacts and that’s your disconnection from people. So now I feel like I’m disconnected from people. So that’s the third domain.

The fourth is self-harming and self-sabotaging behavior. So, you get in the way of your own success, because you don’t think you deserve that success. You don’t think you deserve goodness because of these calls that you’ve made. You try to get in the way of becoming a better person or being successful in your life.

The fifth domain is emotional aftermath, so that’s when you think, the shame. I’m ashamed, I’m guilty. I feel betrayed. So that’s the emotional aftermath.

And then the last one you’re looking at is beliefs about life, meaning, and purpose. And that I’ve lost a sense of meaning of life. It’s different than the other one where it’s about being disconnected or feeling like you’ve lost faith in goodness, but it’s because you now lost, in general, the meaning of life. Like you don’t even have that sense of purpose.

And we know within the military population, especially with our Veterans, when they come back, they’re struggling with transition. It’s the purpose that they’re usually feeling like they’re missing. And so now imagine that at your core, you’ve also lost meaning to life. So that’s someone who’s really struggling.
So that’s the outcome scale we developed, and we have 17 items now. It’s been validated in the research context, and we now need to validate it in the clinical setting. So when you say that there’s 17 items that have achieved validation, does that mean that there is a meter stick for this?

Brian

At the research level, there is. So it’s been validated at the research level, right? So because our paper recently got released in Frontier Psychiatry, that means it’s been accepted into the research world. The next step is to take that scale and run it at the real life in the clinical setting. So working with physicians and clinicians to say, “Okay, ask these questions.” You rate the scale and then you’ll see. When someone rates at four or five on 11 of the 17 items, then we – again, these are hypothetical numbers – but then you can say, “Okay, this person is struggling with a moral injury,” but we’re not there yet.

Brian

So in the military environment, new ideas are almost automatically greeted by resistance and people that don’t want to hop on board. Is that true in science? Do you see that, even though you feel you’re making this forward progress, these achievements, that there’s people going, “Eh, I don’t know?”

Fardous

Oh, absolutely. There’s still a strong discourse within the research community and the science community around is moral injury even distinct enough from PTSD. That’s happening to this day, to this moment. So there are folks that will say that it’s a subset of moral of PTSD, moral injury is a subset of PTSD, that it should be captured under that umbrella, and others are saying that it should be distinct. So there are two camps, and there are conversations happening where one is convinced trying to convince the other. So yeah, even at that level there are conversations.

Brian

And do you find then that when there’s different camps and some are for and some are against, does that persuade some other folks in the community to go, “Ooh, I don’t want to touch this, this is controversy”?

Fardous

Yeah, it does. It can skew folks’ feedback, because there’s some strong researchers in there who have long years of experience and credentials and they’ve rightfully done some excellent work and so they might be taking the floor with their loud voices.

But we need those others, the up-and-coming researchers to say, okay, sure, there’s a healthy conversation happening, but as a result of that healthy conversation, together we need to move the agenda forward. So yeah, folks are reluctant, but I think there’s also a huge core, at least in Canada, of some strong researchers on moral injury and I’m really looking forward to them because they’re thinking outside of the box. And some of them are in the Ottawa area and are based in our own network. So I’m excited to see what they come up with.

Brian

I’m always trying to look at this from, what would the Army, Air Force, Navy do if this was fully accepted and everything we ever put forward on this, yes, they agree? Okay, so what would they do about it? When we come up with something that could happen in a traumatic scenario, take a mind strike.

We build acronyms, we run you through drills. We’ll buy equipment that handles that thing as best we can. We’ll send you to Spain if Spain’s better at it than we are. We’ll do a lot of things based on trying to show you a little bit of that traumatic moment, so it’s somewhat familiar when you find your way in it.
What would we ever do to prepare someone for moral injury, considering it’s just so wide and so open as to what could be morally injurious?

Fardous

That’s an excellent question. I don’t know if you can really prevent moral injury, and I know I’ve had a conversation with a few colleagues where the job that you sign up for, you know that there’s going to be trauma. You know that there’s going to be moments where you’re going to be experiencing things that are quite distressing. So we can’t prevent that. Well, what’s the secondary level? So now let’s say we’ve told you like, hey, you’re going to get hit by a bus. How are we then going to prepare you as a result of being hit? We may not be able to control the fact that you’ve been hit, because of the circumstances of war, the fact that you’re going to be witnessing these situations, but our job is now to prepare you. Once we know that you’ve witnessed this, how can we support you at that level? And then that’s where at the organizational level I think there’s large conversations we need to have where folks need to prepare the community, especially those folks that are being deployed, that this is what you may see, and as a result of seeing this, these are the things that you should be doing once it occurs. So that’s from a preventative metric. At the team level I think we have to look at leaders within organizations as well to say, okay, your job knowing that you’re going to be putting your staff or your platoon in ways of doing this kind of stuff or witnessing this, how are you then preparing them when they come back from a circumstance like that? Are you making sure there’s enough time for a debrief?

Brian

I think actually we’ve made a lot of progress and one of the areas I think there was progress is every leader that I ever dealt with by the end of my time in the Forces realized that their door had to be relatively open. Can’t be as open as a lot as you think, by the way. You can’t open it to every crazy idea someone can come up with. So it’s somewhat open, but it’s certainly open to people coming in and talking to you about something going on. But as the person inside that office where someone else might come darken that door, there were things I was a little afraid about.

If someone comes up and doesn’t know what’s going on with their career, I’m good. I can coach that person through that. But if they come up to me and they’ve got something more on the domestic side, I’m not so sure I’m prepared for that. And even now as we discuss this and I kind of do some work in the space, I don’t actually know what I would do all that much as the leader saying my door’s open, and someone comes in it with a morally injurious event. Because it’s all in the background, it’s all in the experience, it’s all in that person handled and felt it that way, and I wonder what we can do about that down the road. And my gut is, we’ve just got to talk about it some more.

Fardous

That’s the place to start. As you mentioned, the fact that your door was open, the fact that folks could come in and have that conversation with you, you’d be surprised how far that goes. Just the idea that I know I have a leader in place who’s willing to hear. He might not have all the answers, he might not even be prepared to take in this information, but the fact that he has his door open and I can walk in and share what I witnessed or what I just had to go through… that goes a long way. The second is, I think we’re learning within even the health care community, because we can apply research right here at home is having a cohesive team is key. It helps with team morale, you know?

So as a leader, your job is to ensure that your unit, your team, is as cohesive as possible because then they can rely on one another, and then we can have a full conversation around the power of peer support within that, right? So if your team’s feeling like they can support one another, they’re going to turn to each other when they’re struggling. So that cohesive unit is really important.

The second as a leader, again, I think it goes without saying, but it’s encouraging self-care. So, you have to ensure that your team has the time that if they do, again, witness something, or as a result of making a choice that violated their core moral beliefs, that they have that time for self-care, that they have that time to themself to be able to debrief, to be able to try to make sense of it. So you have to make that space and that time for it. And as a leader, it starts there because we can’t – I think what we’re learning, a lot of folks are saying is that, let’s put it back on the individual, right? And that’s not fair. What are they going to do? What’s that person going to do? They’re the one who’s now struggling with the moral injury and now you’re also saying, “Go make yourself better. Go get help.”

Brian

So, Laryssa, one of the things I think that I really want to get to here is, these are the things that I’m least likely to want to talk about.

Mm-hmm. , I actually do have an easier time talking about trauma, traumatic events and the things that I know you’ll understand what’s bothersome about it. So you’ve been the military spouse, but you also worked with a lot of Families, are still working with a lot of Families. How much does this ring a bell from that perspective?

Laryssa

In that the Veteran doesn’t want to disclose and talk about it?

Brian

Yes.

Laryssa

As I said before, I think it’s hard for Families to understand. They interpret it as a disconnect in their relationship. And I can’t think of many things much more, I’m going to use the word intimate, than a moral injury. I think the person’s trying to come to terms with things that they don’t fully understand. And so I think it would be really hard to disclose it to Family members. So yeah, I think there’s often a disconnect there.

But if I can, I’m going to shift it a little bit because I wanted to explore with you a little bit more, Fardous, about what you might have observed as far as the impact of moral injuries on Family members. And I’m hearing you say that the conversation and exploration research around moral injury in itself is just so new, but are you seeing Families included in that exploration?

Fardous

Yeah, it’s an excellent question, Laryssa. We talk about moral injury research being new, but then when you add the Family component into it, it’s quite novel. So outside of anecdotally hearing these conversations where Brian just said that this is something I’m not willing or I wouldn’t want to share, it’s very difficult for me to share. So then the Family member’s left to say, “Okay, why is my companion, my most trusted individual, my trusted ally not willing to share anything with me?”

So there’s that sense of, “Am I not good enough?” as well. So there’s that secondary trauma that’s coming as a result of this person trying to protect you, but you’re feeling like, “Oh, I’m not the person that they can trust anymore. We share everything. Right? And they’re not willing to share this with me.”

So that’s also additional pressure. And then when they do share, so imagine then, as Brian said, do you want me to share with you that I left children that weren’t being fed? I’m a father, or I’m a mother, or I have someone that I take care of, and now do you also want to know that information about me? How are you going to now perceive me? So it makes you start doubting again, like the person that I’m sitting across from.

Laryssa

And I think in addition to that, you talked, Brian, about some of the Families that I supported. Some of the observations were not just then about the dynamic of, okay, I’m seeing you in a different light, you as the Veteran, I’m seeing you in a different light than the person, the woman, the man that I married. But if the Veteran chooses to disclose, you can’t unring the bell. So now the Family members hear about humanity’s inhumanity. They hear about things that we can’t even dream about.

We see them in movies, just the incomprehensible things that happen on this planet. And so, the Family members are left to question their own moral compass. “I thought the planet worked in a different way than this.” And so now in some ways I’m curious to know if Family members can have moral injuries in their own experiences. And it’s strange because it’s through the lens of what the Veteran is disclosing. And then even beyond that, how are children impacted? They’re brought up in a household where usually their moral schema are developed by their parents, it’s a generational thing, our values or ethics, that kind of stuff. So when you have a Veteran whose moral compass is skewed, how is that experienced by the children? So the next generation kind of thing.

Fardous

So I think of vicarious trauma, right? I think you’re, as a result of hearing someone else’s experience, it might not be your direct experience, but hearing an experience from your partner, the Veteran, and then hearing, because I’m sure they’ll share it multiple times with you, so you’re reliving it as well. You weren’t there per se, but you are reliving it through your partner. And as a result, knowing also that your partner went through that, that additional pressure is now put on you. Like, “Wow, this is my loved one and I know they’ve gone through this and they had to make this decision. I feel for them. But I also am wondering why they made that decision.” Because you might not know the rules of engagement. As Brian mentioned, there’s certain things, calls we make, the door – I want to leave the door open as much as I can, but sometimes I can’t leave it open for you because of my job, the inherent nature of the job, I can’t share everything. Right? So you would question, why did this individual do this? But that individual will have some reason for it, right? But they can’t share that with you.

Brian

And it does get reversed though sometimes, like in any relationship, you’ll have these moments where something’s on the other person’s mind and they don’t want to talk to you about it right now. That sucks. That doesn’t feel good. When someone close to me says something to the effect of, “I don’t want to talk to you about this,” I hate that. It makes me – well, I’m obviously guilty of something. I’ve done something wrong, and you start walking down this path, so I get why the person on the other side doesn’t want to hear that.

On the other hand, I’m not so sure that they get where we’re coming from. I think the other thing, too, that’s really common in my mind with this is you may not communicate what’s important, but you are going to communicate something. I came home once to a grouping of people close to me that basically thought that I was on a European vacation.

Well, some of that’s my fault. Some of that’s because the only things I showed them of my deployment was an R&R in Budapest, or this is when I went on leave in Germany. So basically I showed them this three week snippet of me having a blast, and that was the only thing they really had to figure out what I was doing.

So they treated me when I got back like I’d been on holiday, and I have to look back at that now and go, yeah, but my lack of communication built that reaction. So I own some of it. And to me, that’s all related. Moral injury impacts communication, communication impacts the relationship. So an incident that bothered me from 20 years ago can affect my kids independently today? Yes. Yes, it can.

Fardous

And so, having that open communication, as you just mentioned, Brian, so you understand the side of the Family member, as you mentioned. So you understand that this person is saying, “Wow, is it because of it says something that I did, that you’re not trusting me with this information?”

So you understand that, and it’s important for the Family member to also understand that at some days, in some moments, the individual may not want to share, right? So allow that space, allow that safety. Don’t take it personal, right? And that’s where I think, if we had that education and we had that conversation, as the Veteran, as the Veteran Family member, don’t you feel like that would go a long way if you had some education or some training to know that the reason why my partner is not sharing is because it’s this reason and it’s not something personal. Don’t you think that training and education could go a long way?

Brian

And we all work in this space from different angles, but you just found out within this last hour that you work with someone who hasn’t fed kids when they could have, and I worry about how you’ll react when you hear that. And I know how you’ll react. You’ll react positively because you’re my friends, my colleagues, and it’s your job to know this, but still that trepidation is there. Well, what do you think that trepidation is like when it’s my neighbour or someone who really has no stake in our relationship?
Or the other way where burning that relationship – wife, kids – is so risky that it’s like, well, would I want to risk alienating a kid off telling them what I just told you? No, I’m bearing that one. I’m absolutely bearing that one. And I did for years, and for me that’s part of it. I’m protecting you, but I’m really protecting how I think you might react to me.

Laryssa

So I think, kind of in relation to that, maybe is if folks understood it better, and something you just mentioned, Fardous, was about training and education. So is there some place for people to go to educate themselves more about moral injury, whether they be a Veteran who might be suspecting that they’ve experienced a morally injurious event, whether it’s Family members, or even service providers that might want to learn more about it?

Fardous

Yeah, I think it is shameful self plug of Atlas, in our work that we’re doing.

Laryssa

That was not set up by the way. No, it wasn’t (laughs).

Brian

Well done!

Fardous

So yeah, of course on our website, where as Brian mentioned, as I mentioned early on, that this has been a priority. When we started the organization, we put the stake in the ground and said moral injury is going to be one of our priority areas. And you’ll see us continue doing work in this space until we feel like we get to a place where it’s recognized as a formal diagnosis, which will then be a potentially huge win because then hopefully Veterans Affairs Canada will start covering it. But yeah, to Laryssa’s point, there are others who are doing great work in this space. Canadian researchers, international researchers out of the US, Australia, the UK, Denmark, Israel, everyone is.

It’s impacting everyone, all the different service members, right? So we have to make sure that we’re all coordinated and consolidating this information so people have that one stop shop. And that’s what we’re trying to do. That’s Atlas’s mandate, is that regardless if it’s two, three in the morning, if you’re scouring Google, we don’t want you to be struggling to find information.

We want you to have it all in one place. So that’s why, for Veterans and their Family members and service members, I think we’re looking to offer trainings where we’re working with other clinicians who have that real life experience at the ground level, let’s say, okay, as a clinician, what did you wish you knew? And I think Brian can speak to this, I’ll be interested from his perspective, is if you walked in and a clinician said, “Actually, you might not be struggling with PTSD. This doesn’t sound like PTSD. This sounds like something else.” How many years of stress and that weight on your shoulder do you think you would’ve saved if someone had shared that information with you from the get-go?

Brian

Well, I think there’s a lot of grace and space that you get mentally when someone knows what’s wrong with you. And even if they don’t know what you’re going to do, when they turn and say you have an X, you tore this, you broke that, or this is what you’re suffering through, that helps. And I think we should to some degree shamelessly plug this because when I talk about being bold and brave, bold and brave as a firefighter is doing one set of things, but bold and brave in this space… it is a space of controversy. It is not a space where everything is ironed out and the path is lit.

It’s also not a space where everybody agrees. But Veterans and their Families have said to us that these resonate with them. These things ring a bell. This is what they’re struggling with. So for me, I’m really proud that we’re working on it. And I tell people that. I’ve presented something to you guys, though, and I think at the very beginning, it didn’t go over like a lead balloon, but it went over as a bit of a shock.
I illustrated to my colleagues what it’s like to come down the escalator. A good friend who works with us as well, he’s described a time where he came back and just lost two mates from overseas, but the main argument in the city is are they keeping their hockey team? And that’s a real argument, I don’t want to lose my hockey team either, it’d be great if they won something for once, but I don’t want them to go away… that said, it is tough when you’re coming back from these real moments, and part of it is this. If you look at World War I, World War II, conflicts like that, the whole country was at war. The whole country is saving butter and turning in extra pots. The war effort was coast to coast.

Now, with these conflicts that we’re involved in are a lot smaller and just the military is going, it can feel like we’re going to war and you guys are going to the store. We’re coming back from something traumatic. Down the escalator is a bunch of people figuring out which iPhone they want to buy next. And that is a… I’m compartmentalizing everyone, but it feels like you’re coming home sometimes to a country who hasn’t a clue what you were up to. Not a clue. That is a struggle. Is that a moral injury though?

Fardous

Yeah, I think, I don’t know on the continuum where it lies. But I feel like, again, the experience that you’re sharing is your experience, right? So again, if you’re feeling a sense of betrayal from the community that you’re coming back to because you’ve sacrificed – you and your colleagues, your mates, you’ve sacrificed at a highest degree, and folks are not recognizing that, or folks are not even addressing it, they’re going by their lives, I think there is a sense of betrayal, right? There’s like, you have no idea what I went through for us to keep the freedoms here. So yeah, I think that could be considered – again, I think it’s still an area that we have to research, but institutional betrayal is something that we’ve discussed and I think we need to discuss a bit more, but there could be betrayal from the community.

Brian

Well, there’s also tough spots about handling response time, right? Like, if you look at it this way, if an incident happened, we’re sending a quick reaction force out within minutes. We’re going, the government wants action, and we’re the guys. Off we go. That same person comes back and hears, “Well, you’re going to wait 18 months for that, or that takes 16 weeks to process that file.” You know how horrible that feels because we’re comparing it sometimes to the response time you expected out of us when you needed something. Well now I need a medical assessment and I’m sorry, I don’t want to wait. I don’t think I really ought to wait like that. But not only is it the waiting, I’m comparing it to when you needed something and I was Johnny on the spot as good as I could be. And man, that just doesn’t sit when you’re comparing it to what you get.

Fardous

You had our back, right? And it’s appropriate for the country and others in there to have your back when you come back. So yeah, it’s a fair assessment to say I was able to drop everything, I was able to do this as quickly as necessary for our country. And now when I come back, I do feel like I may have been forgotten. So you know that again, these are components of moral injury that you’re describing at the very minute level, but it’s important to capture that because I’m sure your experience is not only unique to you, so others might be hearing this and saying, wow, what Brian just described there is something that I’ve felt. I may not have known that that is a potentially morally injurious event.

Brian

Well, and I think as well, military sexual trauma, for example, is a massive problem. If you’ve got one circumstance of it, it’s awful, let alone the amount of circumstances that we have. So it’s a significant problem that’s happened. And I look at a lot of these incidents though, and sometimes I look at some of my friends who have been hurt in service – so while doing the job I signed up to do, this bad thing happened to me – and then I look at others that were hurt by the service and I get the sense that the moral injuries tend to happen more. Where you think you were hurt by the service, you were let down that team that said it was there for you was actually your perpetrator, is it a fair assessment to say that those hurt by the service injuries tend to be on the morally injurious side, or is it maybe just how it’s playing out as I’m looking at it?

Fardous

I don’t think definitively we can say one is more morally injurious than the other. But yeah, institutional betrayal is high up on the impacts of the potentially morally injurious events. So as you mentioned, when being betrayed by the institution as a result of, you agree to take this up, you agree to do all this, and then you find that the folks that you agree to do this work for have now put you in a position for something horrible to occur to you, there is for sure moral injury, but I don’t think it’s definitive that we can say one is more than the other.

And sometimes it might be a compounding effect, right? So let’s say you get hurt in service and then by the service. Imagine you get both of that, then we know that person is going to be in a very rough situation. So, I don’t think it’s been researched, I don’t think it’s been actually identified as which one is more than the other, but you do open a conversation that needs to be further explored.

Brian

So where are we going next? What do you think’s happening in the world of moral injury in the next one to two years that’s reasonable that we would get there?

Fardous

Well, I think the scale that just came out, right, the moral injury outcome scale that was in partnership with all these different countries. My hope and my vision is that we take that scale and run it at the clinical level, right? So if we can actually validate this at the clinical level, and then we start using it, and then we can start diagnosing folks that might be showing higher symptoms of moral injury.
If we get to that place, we’re ready to go. I think that’s the next step. The other is, the conversation we’re having. I don’t think we can lose sight of – even Brian just shared, someone who works in this space, who’s been an advocate for many, many years, even feeling some trepidation to share this information.
So imagine someone like yourself who you know is in a good place in his recovery journey and has his colleagues around who understand the space, but still feels a reluctance to be able to share. There are others that aren’t even close to that already. So I think we need to make sure that the conversation continues occurring and that we don’t lose sight of the importance of that, the power of that. And I think we all can speak to, when we sit down with some stakeholders, especially RCMP Veterans, we talk about what moral injury is and they’ll be like, “Wow, that’s the first time I’m hearing that.”

Brian

That is what I get all the time! I first get, “What is that?” and then, “Absolutely. That’s what I’ve been talking about for X amount of years.” And they didn’t have a word for it. Hey, is there a vicarious side to this? Like, can you spread it? Can I have moral injury and now my wife’s affected down the road and my kids are?

Fardous

So I think that was the conversation we had earlier. That’s why folks might feel like, a Veteran might feel like, “I don’t want to share with my Family member because then they might be impacted by it.” But if you share and then we walk away, then yes, that can cause some impact. But if we share and then we talk about, “Okay, how are we going to address this together? How are we going to make sure that we have the supports around us to be able to get through this? When do we need to seek professional help?”
If you have that conversation, then you’ll be in a lot better position versus just sharing and then walking away, right? Because then you’re like, okay, now I’ve maybe dropped something on this person. Then now they’re starting to make doubt a lot of things, and I’m not going to support them, then that’s harmful. And I think we’ve always had that conversation in mental health, unfortunately.

Laryssa

I have a big question I’m going to drop on you. It might be hard for you to answer.

Brian

These are the best kind! (laughs)

Laryssa

There you go, the last minute nth hour to drop it!

You kind of talked about where things will be advancing with moral injury as far as the moral injury outcome scale and things like that. But for an individual, for someone who’s listening, this is where it may be hard to answer… what’s on the other side of moral injury?

Fardous

Moral growth. Moral resilience.

Brian

That’s a thing?

Fardous

Yeah. I think we didn’t get into it a little bit today, but there is the positive moral growth as well. So certain situations that you may deal with and then there’s the result of that, because you’ve had the supports around you and you’ve been- you’ve had the conversations that you need, you may be able to grow from that. To say in a circumstance following that, “I may have acted differently” or “I may act differently. I made sense of that situation, but now I know where my compass lies and what I’m not willing to sacrifice.”

So on the other side of it, there is moral growth, and it is a journey. I think someone, even if anyone’s struggling with PTSD, you get the supports and it’s recoverable, someone could get better from it. Moral injury is the same way. So if you put the right supports around an individual and they have professional support, then there’s moral growth, there’s moral resilience.

Brian

I smell a follow-up podcast coming here! Moral growth, there you go. I think this is a unique episode for us. First of all, this is front and center with me. These are the things I want to work on. But it’s almost like people are watching a really small internal staff meeting. This is how stuff gets done here is it starts with the conversation. And I think of when we go to the community, and it’s actually one of the things we’re doing tomorrow – it’s why we’re all in town here – is we’re having a get-together of the main folks that are advising us. What do you guys want to talk about? And the very things that you think are too hot for a conversation are probably where we need to go. I’m really excited that we can be brave and bold enough to have this conversation, particularly in a space where we’re asking you questions and you’re coming forward saying, well, we don’t know that yet. We’ve still got more to do there. That’s brave, but that’s where I want us to keep going.

Laryssa

That’s great. Next mini staff meeting, someone’s got to bring the donuts and coffee. But, thank you so much for joining us today, Fardous.

Fardous

Of course. Thank you for having me. I hope that was helpful.

Brian

So as we wrap up, again, we’ve got Laryssa Lamrock here, Brian McKenna, and Courtney is of course our… what would you go with? I would go with director, producer, all things that make it work.

Laryssa

The glue, I think.

Brian

And we’re fortunate enough to be joined by the boss, the CEO, by Fardous Hosseiny, to speak to us about moral injuries.
So I really appreciate you making the time and coming here today.

Fardous

Of course. Yeah. Thank you.