Podcast Episode 011: Moral Injury with Dr. Wyatt Evans

​Does your spouse have a moral injury? What about you?

What is a moral injury anyway and how do you recover from moral injury?

In this episode of The Communicate & Connect Podcast for Military Relationships, Elizabeth Polinsky interviews Dr. Wyatt Evans on moral injury and how spouses can help their partner who may be recovering from a moral injury.

IN THIS PODCAST

SUMMARY: 

• What is moral injury?
  
• How do you get one?
  
• What can spouses do to help?
  

MAIN POINTS:

1. Who is Dr. Wyatt Evans:
Dr. Evens is a board certified psychologist at the Veterans Affairs Hospital, and has a private practice in Dallas - Fort Worth. He also teaches, writes, and conducts research on moral injury and resilience enhancement. 

His research uses an Acceptance and Commitment Therapy (ACT) perspective. ACT is an evidenced intervention  for a full range of mental health and non-mental health issues. ACT has over 300 randomized control trials supporting it’s efficacy. ACT is a process based cognitive behavioral  therapy that is built around a concept of psychological flexibility which covers topics such as enhancing acceptance, becoming more mindful, clarifying personal values, and living life based on those values.

Acceptance and Commitment Therapy is all about accepting painful thoughts and feelings in order to go toward what’s really important in life” -- Elizabeth Polinsky 

2. Three Definitions of Moral Injury:

1. The result of a morally injurious event often in a high stakes situation where someone feels they or someone else has violated a moral value.
2. Moral pain is “the experience of dysphoric or painful moral emotions”. This may be guilt or shame if I violated my own values. Or it could be anger or disgust if someone else violated my values. There is nothing pathological about it. It is what we ought to feel in response to a violation of values and morals. 
3. Moral Injury is the expanded suffering that comes from trying to rid ourselves of moral pain. According to Dr. Evans, “It manifests when I struggle against that moral pain”. 

It's an injury because its now preventing me from living my life” -- Elizabeth Polinsky

3. Moral Injury and The Military 
Moral Injury is not exclusive to the military but is often discussed in a military context because combat situations often involve moral injury.

Example: Killing a child in a combat scenario often causes moral pain. A service member might be ordered to kill a child; may encounter a child that has been weaponized and they are stuck between killing the child or allowing the child to put lives in danger; or times when targets are unclear and civilians get caught in the crossfire. To most people, these will cause moral pain—with emotions such as guilt, deep sadness, shame, as well as self-consuming thoughts like “what type of person am I?" or "what type of soldier am I?". These are actually adaptive because they prevent us from getting numb to these atrocities. 

But imagine that the service member comes home and they hear their kids squealing with happiness. They may start avoiding their child because they end up remembering the kids that were killed in the war scenario when they see their kids happy. They feel guilt from the original event, but now may also fell guilt from being distant from their kids--this causes disconnection from their values of caring, connecting, and protecting in there family. Now there is a perpetuated disconnection from their moral values. 

The values and the pain are two sides of the same coin... the fact that I feel guilt means my moral compass is still intact” - - Dr. Wyatt Evans

4. Other Causes of Moral Injury:
Caveat: There is some debate over what constitutes a morally injurious event. It usually takes place in a high stakes context where physical and psychological threat are significant. 

• Intimate partner violence could be a morally injurious event. If someone feels in danger, then it could lead to moral injury for both partners. These events can be acts of commission, or purposeful active transgressions, by self or others. 
• Example: One partner is stressed and drinking, and they react with violence when they never have before. Typically they are kind and caring. Both of the partners are likely to experience moral pain. If they feel immense guilt—they ought to feel this moral pain and it lets them know that they messed up. There are a few ways of responding. If you withdraw and feel like you are unforgivable, or unworthy of love, or if they immediately end the relationship—then they are likely now experiencing moral injury. For the partner who is feeling anger, contempt, disgust, or sad at the betrayal of trust—these feelings are natural. According to Dr. Wyatt Evans, “It is how we respond to emotions that is especially meaningful”. If the partner gets consumed by anger and retracts from the possibility of a romantic relationship in the future, isolating from anyone; then their life is being directed in unhelpful ways by their moral pain making it a moral injury. 
• As a side note, PTSD is different than moral injury. PTSD is about an exaggerated fear response. But contempt, disgust ,and a distrust in people to adhere to values and morals (i.e., thinking everyone is dishonest and untruthful)—then this is probably more like a moral injury.  ​

5. Healing from Moral Injury
This is still under investigation. There is not one type of therapy for this yet—but there are several studies that have looked at PTSD treatments for moral injury such as Prolonged Exposure and Cognitive Processing Therapy. Other treatments include Adaptive Disclosure and The Impact of Killing Protocol. Lastly, Acceptance and Commitment Therapy has potential for moral healing. 

Moral Healing has 5 qualities: 

1. Acceptance of the reality of past moral wrongs
2. Openness to moral pain 
3. Flexible consideration of moral rules in favor of underlying moral values 
4. Awareness that the sense of self is separate than the moral pain (I have guilt but I am more than my guilt)
5. Actively living values from moment to moment—including he values that had been violated. 

​
Dr. Wyatt Evans and colleague wrote a workbook on moral injury that can be used by:

• Those who are suffering from moral injury,
• Professionals working with those who have moral injuries,
• And partners of individuals suffering from moral injury.

​
The workbook can be an aid in moral healing. The workbook has 3 parts: understanding moral injury and moral values; core ACT processes; and forgiveness, compassion for others, and self compassion.

6. Words of Wisdom from Dr. Wyatt Evans:
1) Encourage care—self care and professional care.
Moral injury isn’t a mental health disorder, but it often does require extra support from a professional in the recovery and healing process. 

2) Don’t collude with avoidance.
Oftentimes partners and family members are attempting to be helpful in allowing avoidance of emotional pain, but it actually deprives the person of staying connected to their values. Stand next to them and with them in the emotional pain of the moral injury. 

3) Invite and encourage connection.
Moral injury is a social wound—a fraying of the fabric that connects us together. Invite them to stay connected and in touch with their moral values. 

Working with Dr. Wyatt Evans:
Dr. Evans has a small private practice in the Dallas/ Fort Worth Area. For more information on working with him, see www.drwyattevans.com . Purchase The Moral Injury Workbook here!

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Thanks for Listening!

Elizabeth Polinsky is a marriage and couple therapist specializing in working with military members, veterans, and their families. Liz is located in Norfolk, Virginia, and provides online counseling services throughout Virginia, South Carolina, and Arkansas. ​

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