MORAL INJURY TO MORAL RECOVERY

By Bill Bograkos , MA, DO, FAOAAM, FACOEP, FACOFP, COL MC FS COL (retired)

By

Bill Bograkos , MA, DO, FAOAAM, FACOEP, FACOFP, COL MC FS COL (retired), deployed on 9/11 and cared for traumatized troops until 2019. After retiring from military medicine he spent seven years on the Trauma-Recovery Service, Psychiatry Continuity Service, Walter Reed National Military Medical Center, Bethesda, MD, USA.

While his ER days are in the past, he now serves with the New Hampshire state Veterans Suicide Prevention Committee and holds teaching appointments @ www. USUHS.edu in the departments of “Military & Emergency Medicine” and “Physical Medicine & Rehabilitation”.

My name is Bill Bograkos, and I am a retired military physician. I became a member of the ACOEP in 1993, and have spent the last seven years serving as a consultant on Trauma Recovery, Psychiatry Continuity Service, at Walter Reed National Military Medical Center in Bethesda, Maryland. Prior to that, I cared for Service Members with severe traumatic brain injuries. My career extends from emergency medicine to rehabilitation medicine.

It has been almost 40 years since living and training in New York City. Thank you to all First Responders and First Receivers for your service. You certainly are fighting the good fight, and finding the “good trouble”. Hope you are all keeping the faith in yourselves, and in something greater than yourselves.

I survived medical training in New York City, so the military sent me to the “Survival” school at Fairchild, AFB, Spokane, WA, USA. During the 1980s, USAF SERE (Survive, Evade, Resist, Escape) Instructor cadre were survivors of POW internment camps in Vietnam. These survivors taught “so others may live”. Teaching others to survive kept them alive. There were other Veterans living in the Cascades alone, like many Veterans across the country in isolation. The darkness of isolation never allows growth in a survivor’s recovery. Trauma recovery like Disaster Recovery, requires communication, cooperation, coordination, and collaboration with others. Victims isolate. Survivors engage.

Trauma- and StressorRelated Disorders are discussed in the DSM 5.(1) Criteria for Post-Traumatic Stress Disorder (PTSD 309.81) includes A) exposure to a traumatic event, B) intrusive symptoms (while awake or asleep), C) avoidance of reminders or known triggers, D) negative alterations of cognition and mood, E) alteration in arousal, changes in the autonomic nervous system including sleep disturbances, F) duration of psychological pain of more than thirty days, G) the disturbance causes distress or impairment (disorder), H) the disturbance is not attributable to substance use disorder (“Addiction is a brain disease”) (2), or another medical condition. More than 50-60% of people with PTSD abuse substances. Mood disorders are common co-occurring disorders in both PTSD and traumatic brain injury. Traumatic experiences may have involved feeling helpless and hopeless while witnessing others die.

When we experience chest pain, our brains guide us to the Emergency Room.

When we experience a traumatic brain injury, a toxic brain injury, or psychological trauma, we depend on others to help us find our way. When we experience a moral injury, we may repress and depress, or we may choose to connect and communicate with ship “mates”, “battle buddies”, or our “wing man”, within civilian or military communities.

Moral injury is a profound violation of a person’s core moral identity. Guilt, shame, and betrayal are hallmark reactions to moral injury. (3) In healthcare and warfare, experiences may be related to life and death triage, resource allocation, policies felt as betrayal, or dysfunctional leadership. The combination of PTSD and moral injury is associated with greater PTSD, greater depressive symptomatology, and greater suicidal thoughts and attempts. PTSD is largely fear based where shame and guilt drive moral injury. Betrayal by peers, mentors, or leaders, or a failure to live up to one’s own moral standards are hallmarks of moral injury.

A moral injury feels like an unrepairable hole in your soul. Imagine how Major (Dr) Andrew Taylor Still felt after returning home from the horror of war and again after he lost his family to infectious disease. He did recover and he did develop Osteopathy for the world.

Moral injury requires repair of injured bio-psycho-social-spiritual structure and function. The path to Moral Recovery involves connecting with others before you drown in guilt and shame. Recovery involves education and self-forgiveness before drowning in self-harm and self-sabotage. Recovery involves grabbing on to that life line thrown from ships. Your mates navigate and sail on these ships and these ships are friendship, mentorship, and leadership.

In Disaster Medicine the stronger Development phase always follows the Recovery phase. Development is often difficult to envision from the darkness of moral injury. Sometimes we require light and guidance from others. Leaders and mentors serve as stakeholders in the development of junior physicians. Our friends, mentors, and leaders may need a lifeline connection with professionals outside of their own comfort levels or safe zones. Trauma is complex and not all trauma bleeds.

Moral injury is not a disorder or disease. It is a sign of mental and moral health in caring for trauma survivors. The injured need assistance in rejoining life and repairing “self”. One suggestion is sharing your story with those you trust and supporting others with your own active listening skills. Prosocial behavior is a form of restitution and a method of healing. Recovery involves cleaning house, helping others, trusting, and serving something greater than yourself. The past is gone forever. Recovery and development involve lifelong learning from our pasts and the experiences of others. Isolation leads to impairment. Stay engaged and stay safe. –•–

References:

1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.

2. National Institutes on Drug Abuse. http://www.drugabuse.gov (accessed October 2, 2020).

3. U.S. Department of Veterans Affairs. PTSD: National Center for PTSD. http://www.ptsd.va.gov (accessed October 2, 2020).