145 - Guilt, Shame, and Moral Injury: Dr Jaimie Lusk

Moral distress, mismanaged, can lead to dysfunction and what we call moral injury.  Today's guest is Dr. Jaimie Lusk, a Marine Corps Iraq veteran and a psychologist from Portland, Oregon, with expertise on moral injury.  Dr Lusk talks to us today about moral distress and injury and what we can do about it, including how ritual impacts your recovery after taking a human life.

Resources:

• Dr Lusk's website is https://www.drjaimielusk.com
• Transform Your Guilt and Shame by Carolyn B. Allard
• Dr. Shira Maguen's research on the Impact of Killing
• Everett Worthington's website on forgiveness is https://www.evworthington-forgiveness.com
• For more on Moral Injury listen to Hey Chaplain Episode 020 with Chaplain Debra Fontes

Music is "Back to Portland" by TrackTribe

Hey Chaplain podcast episode 145

Tags:

Veterans, Betrayal, Guilt, Health, Hunting, Killing, Moral Distress, Moral Injury, Parenting, Police, Psychology, Responsibility, Ritual, Shame, Transgression, Trauma, Values, Portland, Oregon 

Transcript

SPEAKER_00 0:01

Welcome to Hey Chaplin. My name is Jared Altic, and I'm a chaplain with the police department. The Hey Chaplin podcast is about talking to police officers who say, Hey Chaplin, I've got a story to tell and some hard-earned wisdom to share. The guests on Hey Chaplin come from across the world, from the LAPD to Scotland Yard, and from Portland, Oregon to New York City. They are sharing their wisdom with you so that you don't have to learn everything the hard way. And as a patrol chaplain, I think you deserve something positive and encouraging. There are all kinds of things in life that can cause moral distress. And moral distress, when mismanaged, can lead to dysfunction in your life and what we call moral injury. Today's guest is going to talk to us about moral injury. She is Dr. Jamie Lusk, a Marine Corps veteran of Iraq and a psychologist from Portland, Oregon. She has expertise on moral injury and specifically 15 years' experience treating veterans and first responders. Dr. Lusk talks to us today about moral distress and injury and what we can do about it, including how ritual impacts your recovery after taking a human life. Here's Dr. Jamie Lusk. Dr. Lusk, how are you today?

SPEAKER_02 1:34

Great. Good to be here with you.

SPEAKER_00 1:36

I'm glad you're here and glad I'm gonna be able to talk to you. And so can you tell me uh what you've been doing to help veterans uh here in recent years? Dr.

SPEAKER_02 1:47

Well, I am a veteran and served in the Marine Corps from 2001 to 2005. And in that time, I went to Iraq and frankly felt confused and distressed about my participation. So left that and became a bike messenger like you do. And I figured I could just do that for the rest of my life. But as you can imagine, delivering packages and eating chocolate chip cookies and burritos lacked the purpose that I also felt in the Marine Corps. So I found my way.

SPEAKER_00 2:26

Where were you a bike messenger? Where were you at bike messenger?

SPEAKER_02 2:28

Denver. Yeah, Denver.

SPEAKER_00 2:29

In Denver. Yes. Really?

SPEAKER_02 2:31

Mm-hmm.

SPEAKER_00 2:32

And so then bike messengers in Denver. Well, they don't really have a bigger.

SPEAKER_02 2:37

Yeah, it it when I was doing it, it had more need or purpose. We didn't have as as much ability to do things online. So there's a lot of rushing documents from the courts to the lawyers and rushing blueprints from the job site to the architects and back. Nowadays, most of that happens electronically. So it is sort of a fake job now. But when I was doing it, it was somewhat a real job, but still lacked the purpose and you know the honor, courage, and commitment I experienced in the Marine Corps. So I actually wandered into seminary and did get a degree, but didn't get a sense of what I was going to do with that. So then I kept going and found my way into a doctoral program for psychology. And that's really where I felt like a duck in water. I ended up wandering back into the VA with veterans and realizing that a lot of stuff I struggled with was similar to what the people at the VA were struggling with. So really early on, I was working with vets and joining this conversation of moral distress, moral injury, and PTSD. And I've been in that space mostly as a clinician, but doing some research on the side for the last 15 years.

SPEAKER_00 3:56

Okay, so I have to have you define the term. Uh, we're talking primarily about moral injury today, but I feel like every time I go to another seminar, take another class, I'm hearing a slightly different nuance of what they even mean by the term. Why is that and what does it mean?

SPEAKER_02 4:17

Absolutely. Well, first the term was first coined by Dr. Brett Litz in 2009. And I'm gonna go with his original definition because we're still arguing about what it means, but he really started the conversation, so I respect that. And his definition is perpetrating, failing to prevent, or bearing witness to, or learning about acts that transgress deeply held moral beliefs or expectations. There's an event that's potentially morally injurious, we experience moral distress, which is healthy and natural. So that's all those moral emotions: fear, anger, horror, disgust, guilt, shame. That's good. That's a good thing. That's how these systems are supposed to work. And then depending on what we do with that moral distress, if we bury it, if we stuff it, if we um begin doing things to avoid it that then start to snowball on us, that becomes the moral injury. So the moral injury is, I guess you could think of it as you got a hot spot and you ignore it, then it becomes a blister. The moral injury is the blister. It's it's the thing that starts to build momentum beyond the event itself. So moral distress, good thing. Moral injury, that's when we ignore our moral distress, and now we got a thing that's affecting our functioning.

SPEAKER_00 5:45

So when we're talking about the source of this kind of injury, there are several layers baked into that definition. So it can be like an authority figure needed to do the right thing and didn't do the right thing, and you witness that betrayal of what you expected from them, what you needed from them, and that hurts. But then there are injuries that come from our own action or inaction. Can you describe that again? What is it that as a soldier, as a marine, as a police officer, what kind of situations would you be in that could result in a moral, in moral distress and lead to a moral injury?

SPEAKER_02 6:30

Well, so I want to say that I've worked with thousands of people at this point. And what's interesting is it's not really the event itself, but the meaning we make of the event itself that um determines which direction people go, whether they go into this shame-guilt spiral or whether they go into more of a resentment spiral. So certainly some events lend themselves to one or the other more, but let's just take a sexual assault. I've worked with veterans and first responders who become deeply guilt and shame ridden and really blaming themselves for that transgression, and then another person very resentful and really stuck in a sort of uh a helpless resentment spiral. So, same event, people went different directions. So we could say we have these tendencies in our culture and just maybe the way our brains work to immediately need to make meaning of pain. A bad thing happened, it's my fault. A bad thing happened, it's their fault. We gotta go somewhere with it. That's what our brain wants to do, and that's what we're sort of culturally loaded to do. Moral injury could be betrayal based, it could be transgression-based, and it's not necessarily based on the event. That said, we've got transgression, you violated your values, you did something in a moment that violated your values, or betrayal. There's a there's something you witnessed or something done to you that violated your values. So that's kind of an argument as well in the field. The two leading measures right now are the moral injury outcome scale, and that incorporates that's from Litz and colleagues, the guy that's first coined the term. And that measure includes both transgression and betrayal. But then there's another school who's doing amazing work who basically have been studying trauma-informed guilt reduction. And their scale, the moral injury distress scale, only looks at transgression. So in the field, there's a little bit of an argument whether we we make moral injury inclusive of both betrayal and transgression, or we focus in on moral injury as transgression and we make another term that's betrayal or something else. I like them combined because I think there's also people in the middle that are like a bad thing happened. It's my fault, it's their fault, it's my fault, it's their fault, it's my fault, it's their fault, it's my fault, they're they're stuck in this like it's somebody's fault. I can't figure out who.

SPEAKER_00 9:02

And situations are complex, right? There are plenty of situations where I have some guilt. I was there, I had a certain amount of participation, but also I there's other people who are responsible for this. They started it, they caused it, they put me there, and without them, I wouldn't have been there in the first place. And so so I can see the betrayal thing too. And with like in law enforcement, the more common issue is the betrayal. I feel like I am not being taken care of. I am putting myself at risk, and you're doing nothing to help me, and you said you would, and you're not, and that betrayal is a common gripe. Right. That being said, the transgression where I've done something I'm ashamed of, that maybe is less common, but it strikes me as deeper, and that changes someone's outlook on the world if they if they if if they start to redefine who they are because of what they've done, that that could change everything. To me, that seems to have a stronger cascading effect. I'm not sure if that's accurate.

SPEAKER_02 10:12

I think it it it can partly because shame thrives in secrecy, judgment, silence, and those who are experiencing more of that transgression-based moral injury are less likely to share it, less likely to find camaraderie in their suffering.

SPEAKER_00 10:30

So for instance, when someone feels betrayal, they announce it from the rooftop. You know, it's like they wronged me, they promised they didn't keep their promise. And so yeah.

SPEAKER_02 10:40

So I run a group, it's an act, you'd be interested in this because on some level, from the very beginning, I'm like, this is a bit suspicious. We sort of stole moral injury from chaplains. Uh, you know, religions had some things to say about these topics for the whole time. Yeah, religion's been on the planet. So I really early on partnered with chaplain services at the Portland VA, and we've had a psycho-spiritual act for moral injury intervention. Act is a type of therapy, acceptance and commitment therapy. And so we ran an act for betrayal group and an act for transgression-based moral injury group. And to your point, we usually decide what group to do based on who's ready for the group. And we probably do five betrayal groups for every one transgression group. So more people are lining up to get together and face their betrayal together than transgression. And those transgression groups, like you said, there's a bit of a scary holy space there where in the very beginning, are these people going to open up and share and build camaraderie, or are they gonna keep their stuff too close and this group isn't going to do the hard work needed? It there's a little bit of bubble.

SPEAKER_00 12:06

That's the whole conversation around shame. It's so so difficult to bring that out into the light. So let me let me back up a step and ask about our response. Is there any way for us not to assign blame? Whether we're pointing at ourselves or pointing at someone else, it isn't that the natural response? Is it wrong that we're responding that way?

SPEAKER_02 12:30

Well, absolutely not. Um if you've raised kids, you know, you can't teach your kids there's no order to the universe. You can't just teach them, hey, if you work hard in school, who knows what will happen? If you do your chores, you may or may not get in trouble. And in fact, it really doesn't matter what you do in this household. That's not acceptable. We teach our kids that if you do good things, good things will happen. If you do bad things, bad things will happen. So that's that is necessary as a developing human to have some sense of order, that that my actions matter, that I can affect the outcomes in my life. And yet, as we grow, we know that also creates what's called the just world fallacy that good things happen to good people, bad things happen to bad people. So when a horrible thing happens, our brain immediately is going to say, I must have done something wrong. And and that's a good thing in a sense because we need to keep learning from our experiences.

SPEAKER_00 13:31

In most cases, I need to evaluate and see if I did something wrong. Because in many cases we did. Yeah. But that doesn't mean that if you get a report back from the doctors says you have cancer, it doesn't mean you did something wrong that caused the cancer. It could be a random thing. Right. And so so assuming that that just rule fallacy, assuming that that, well, something bad happened, I must be to blame, or someone else must be to blame. Sometimes bad stuff happens to good people.

SPEAKER_02 14:03

Absolutely. And it also works out there in the world. So if you're raising children, you have to at some level believe you can keep them safe. So when this horrible thing happens to a kid on TV, your mind's immediately going to be like, Well, that parent must have done something wrong. That wouldn't happen to my kid because blank. Well, we need that just to get through our day. If you were constantly as a parent thinking about all the things that could go wrong with your kid in any given moment, you probably wouldn't make it through the day. So on some level, our brain's saying, Well, that one happened to my kid because blank, that one happened to my kid because blank. It's it's not just inside of us, but it's every witness ever out there in the world also has just world fallacy.

SPEAKER_00 14:48

If you live or die with every possibility instead of living with what is probable or every probability, if if you if you live and die with every possibility, you you won't last long. You you will fall apart and you will not be able to function.

SPEAKER_02 15:02

Exactly. So we can't avoid a meaning-making bias that overestimates our control. We can't avoid that.

SPEAKER_00 15:11

And yet say say that again. Say that again.

SPEAKER_02 15:14

We can't avoid a meaning-making bias that overestimates our control.

SPEAKER_00 15:20

Okay.

SPEAKER_02 15:21

What do we do next? A lot of the beginning of moral injury work is going back to the event itself and looking at what really happened and how we can make sense of that. So I really love, for instance, I'm just gonna highlight trauma-informed guilt reduction. It's one of the moral injury treatments that has the most evidence basis. Um, and it's specifically for somebody who's in a transgression-based moral injury loop. And again, I said loop because it's not a diagnosis, it's basically a cycle where you're you're stuck, but and it's affecting your functioning, but it's not a diagnosis. The in this treatment, you're evaluating your guilt and you're breaking it up into different parts. So, first you're looking at foreseeability. How much could you have predicted that this was going to happen? So you're asking yourself ultimately the question if I knew for certain this would happen, would I have done something different? And almost always people are like, Yes, of course. But I didn't, right? So they're looking at what they knew at the time. And then we're looking at justification. So a lot of times with law enforcement, there is no right answer. So they're saying, well, I should have done this, I should have done this, I should have done this, I should have done this. Well, was that available at the time? Truly. If it wasn't, we got to cross that out. And then if it was available at the time, what would have been the potential fallout there? Right. So let's say it's an active shooter situation and uh law enforcement officers blame for uh excessive use of force. So that option they chose now, they're in the hot seat for it. They they did something that the public or their leadership has decided they went too far. Okay. Well, there's another option where they did less. What was going through their mind at the time? What would have happened potentially if they did less? Um, what were the perceived consequences of using less force? So now we look at, okay, go back to that situation. What were the reasons you chose what you chose? And if you had to do over again, would you choose the same way? Right? And a lot of times what will happen with law enforcement is they'll have choices that were never available at the time. Well, I just shouldn't have shown up on that call. Well, I shouldn't have become a law enforcement officer. Those aren't options at the time. So we got to cross those out. But our mind tries to undo the thing that's happened with all these sort of false scenarios. And then to your point, you said there are situations where I'm partially to blame. So that another part of this unpacking would be well, let's look at all the people that were responsible. A big argument in law enforcement right now is, you know, the military does 90% training and then 10% mission. But law enforcement is forced to do 90% mission with a very, very short amount, very insufficient amount of training. Um, so in our percent responsibility, how is that factored in? That really you didn't have good training on how to use escalation of force and what are all the steps that um could have gone into negotiation with this person. So again, that percent responsibility is a big part. And then we have to look at did you actually violate a value? And if so, was there another value you were trying to honor? So a lot of times, let's say there's a scenario where you killed someone and that violated your value of um human life. But then there was also a fellow officer in danger. So that was honoring your value of protecting a fellow officer or an innocent bystander. So again, did you violate a value? And if you did, was there a value you're trying to honor? And then at the very end of this, we've sorted out this non-adaptive guilt. There may be some adaptive guilt. Oh, you still did something you want to account for. Okay, great. So then we go into amends and repair and ceremony and ritual and agreeing for all time that you're gonna do things different. That's a that's a treatment I really love for transgression-based moral injury.

SPEAKER_00 19:32

I don't know if you have a percentage, but in your estimation, how many moral injuries revolve around a death of a human being?

SPEAKER_02 19:43

Well, that's interesting. There's another treatment that's not yet publicly accessible that's been researched out of the San Francisco VA, that's impact of killing. That's all it is, impact of killing. So we know specifically killing affects us in a unique way. And people talk about crossing that threshold and it's unexpected that it would affect them the way they did because they were training perhaps to take a human life in a situation. I would say I don't know about percentage, but it is a unique factor. So if you look at the impact of killing research, they've isolated in different studies, well, how much did killing a human itself impact this person? So I can't tell you exact percentages, but it has a unique um impact and is talked about as a unique experience that that needs to be honored in and of itself.

SPEAKER_00 20:36

A lot of uh veterans that I know, a lot of officers I know that have taken a life in the hours immediately after which I interact with them during the those hours and those days, they almost universally feel compelled to say how well they're doing. They're like, Oh, I'm fine. I'm fine. You know, uh you know, hey, hey chap, I'm fine. Right. And so so they they want to to say that they're okay. Um, and what uh what I usually encounter is a long period of time after I had an awards ceremony where they're being celebrated for an event that included taking a human life, then they'll express to me, man, I don't feel great about this. And you know, this is bothering me that you know, this is the third award ceremony I've gone to, and I killed a person. I don't know how I feel about that. I'm sure I had a question in here somewhere.

SPEAKER_02 21:37

Well, so I'm wondering just about so it first of all, I would go down the rabbit hole of Dr. Shira McGinn, who's devoted her whole life to specifically researching impact to killing, very accomplished researcher who's done an amazing work in just this. But I even think about hunters who very much believe that eating their own On food and going out into the wilderness to provide for their families is in line with their values. A lot of ethical hunters I know will still take time to honor the death of the animal and what that means for them and their family. So that piece that you might be asking about is even if the killing was justified, even if the killing was in line with values, in line with mission, how does one move into honoring that death of that person and honoring that that a human life with whatever is unique about humans was taken. And so that's actually where I really partner with chaplains, because I've I'm an expert in looking at what the research says and specifically uh human behavior and human emotions. So I love partnering with chaplains who are experts in how we bring ritual and ceremony from traditions into recovery. So I got a I got a truth criterion of science, and chaplains have the truth criterion of tradition. So how have humans traditionally done something with their bodies to honor transitions and honor loss? So I actually cheat and punt to chaplains on how we might use ritual and ceremony to honor loss. So what do you think in terms of what's worked to honor having had to kill someone?

SPEAKER_00 23:34

I think that it is important to treat it with reverence. And young men, military and law enforcement, are typically very flippant. It is kind of a very superficial coping, you know, joking about it, joking about how the person died or what they looked like, or you know, some detail of it. They'll make it a joke and they'll treat it like it was another day at the office and no different than going to get a cup of coffee. When someone's ready, I want to come back and treat this with reverence. And it's not probably appropriate as the officer involved in something that I'm sure is there's gonna be a whole investigation and what have you. It's not appropriate for them to go to the funeral. But man, if I had permission to go to the funeral home out of hours and be like, I'm gonna take this officer and we're gonna go pay our respects, and I'll be with you, and we're gonna say a prayer and and have some ritual. I I would do that. I would do that if I could always arrange it. I you typically can't, but if I could, I would do that, and I think that would lead to better results because I know how important having a moment to express yourself, say your piece, and reconcile what has occurred and treat it with reverence. If we don't treat it with reverence, then that human means less and that diminishes me.

SPEAKER_02 25:02

Absolutely, yeah.

SPEAKER_00 25:03

And so, and so so I don't want an officer to treat feel like, well, he was a bad guy, therefore his life doesn't count at all. No, we're not saying you committed murder, but we're also not wanting to say that this person has no value because I don't want you to start thinking of yourself that way. Yeah, if any scenario involves taking a human life, let's not be flippant about it.

SPEAKER_02 25:28

That exactly. Yeah.

SPEAKER_00 25:30

Let's be professional, let's be reverent, and and if we can include some, you know, ceremony or something like that, I I think that I think some ritual actually helps in that regard. Absolutely.

SPEAKER_02 25:44

And we I don't think we'll get a randomized controlled trial that'll show this or that ritual is the ritual, but we do have research that shows that grief is um facilitated by ritual and ceremony. And so how do we how do we help someone do something meaningful with their body, like you said, to honor and make space for the loss? And a lot of times that includes elemental stuff, burying things, burning things, throwing things in the water, whatever it is. What can you do with this body to say this matters?

SPEAKER_00 26:16

Yeah. What and when you say what can you do with this body, you mean what can you physically act out?

SPEAKER_02 26:22

Right. Yeah.

SPEAKER_00 26:23

That yes, yeah, yeah. Not the other body, right? Your own body. Right. What can you do with your body? Right.

SPEAKER_02 26:30

Can I tell you something that I feel shows up with so I've had two law enforcement officers where they quote, unexplicably started feeling all the grief of everything they've ever worked with. They came to me extremely distraught that they were crying a lot. And and both of these were carrying decades where they witnessed harm to innocent. But they're they weren't actually thinking that that was the problem. The problem was they started crying a lot. That's the problem. That was the morally injurious event to them, is that now they can't stop crying. So so for cops, a lot of times it is this idea of not being able to contain emotions that brings them into therapy and that they feel the most loss of control.

SPEAKER_00 27:20

Loss of control. I had a panic attack, I started whoeping, whatever, and and that's not who I am, or it's not who I want to be.

SPEAKER_02 27:28

Yeah, that's actually the most disturbing thing, not these horrible, horrible instances that they've got.

SPEAKER_00 27:33

Yeah, never never mind all the dead babies you've seen. Exactly. Right, right. Yeah. I can't believe I was crying in front of someone else. That that that's that's the moral injury or the thing that distresses me. Yes. Jamie, thank you for being on the show today. And thank you for doing what you're doing to help veterans and and first responders.

SPEAKER_02 27:52

No, it's been lovely. Uh, I really appreciate your warmth and the way that you think about things so nuanced and and just all the all the threads you hold as a lover of law enforcement and a person that is balancing our spiritual needs as humans with just the practical ways we make sense of pain. I appreciate your podcast and just the way you approach these issues.

SPEAKER_00 28:18

Well, thank you. I want to thank Dr. Lusk for being on the show. She came highly recommended from Matt Dumjanic, who has himself been on the show several times. Today's conversation with Dr. Lusk was actually quite a bit longer. And I have an entire section where she talked about forgiveness, and I'm gonna use that as an excerpt in a future episode. But I did want to include what she said about some of the resources that she mentioned. Those resources are going to be in the show notes in the episode description. But here's Dr. Lusk talking about some of those now.

SPEAKER_02 28:58

Well, I would say if you want to do a deeper dive, I have a free Act for Moral Distress course on my website. So you can you can do that for free. Uh, I love the self-help book that is created by the researchers of trauma-informed guilt reduction. It's called Transform Your Guilt in Shame by Dr. Allard. So that's something if somebody's struggling with guilt and shame and you you really feel like it's affecting your functioning, definitely get that book, Transforming Your Guilt and Shame. That is an evidence-based moral injury treatment for you. Um, the the course on my website is more leaning towards betrayal-based moral injuries. So I recommend that if you're really stuck in betrayal and there's some skills in there that might be helpful to loosen betrayal's grip on you. And and then I would really look at, you know, if impact of killing it is really standing, standing out to you, really look at Dr. McGuinn's research. And again, Everett Worthington also has free do-it-yourself forgiveness manuals on his website. So if anything struck you here, dig in. And if you feel like you're not gonna do it without help, find a therapist who will be a battle buddy. Because if you are in a cycle of moral injury that is affecting your functioning, you gotta figure a way out. And if you need help, find a battle buddy who's gonna make you do the work.

SPEAKER_00 30:23

The views expressed here are the personal views of the host and our guest and do not necessarily represent the views of any law enforcement agency or its components. Dr. Jamie Lusk is a great counselor, but she's not your counselor. The information presented in this episode, including any statements or opinions expressed by Dr. Lusk, is for informational purposes only and is not intended as a substitute for professional psychological advice, diagnosis, or treatment by a clinician who has actually met you. Always seek the advice of your qualified mental health care provider with any questions you have regarding your condition and never disregard professional advice or delay in seeking it because of something that you heard on a podcast. Go see a professional. If you like this episode, please share it with a cop or someone who loves a cop. Thank you for listening to Hey Chaplin. And as always, let's pray for peace in our cities.