Moral Injury: Ethical Issues in Context of Trauma-Based Care

 

Moral Injury: Ethical Issues in Context of Trauma-Based Care from John Gavazzi, PsyD, ABPP

Moral Injury Is an Invisible Epidemic That Affects Millions

Elizabeth Svoboda

Scientific American

Originally published 26 SEPT 22

Here are two excerpts:

A 2019 study by researchers at the Salisbury VA Healthcare System in North Carolina reports that moral injury has different brain signatures than PTSD alone: People with moral injury have more activity in the brain’s precuneus area, which helps govern moral judgments, than those who only have PTSD. And after people suffer moral traumas, they display different brain glucose metabolism patterns than those who suffer direct physical threats, according to a 2016 study by researchers at the University of Texas Health Science Center at San Antonio and their colleagues. The results support developing theories that moral injury is a unique biological entity.

As Brock’s Shay Moral Injury Center found its footing, she forged connections with powerful people who could get the word out about moral injury—including Margaret Kibben, the current chaplain at the U.S. House of Representatives. Kibben holds regular events for House members, and one of her recent talks was about moral injury. The event drew about three times more members than usual, Brock reports, “and they all wanted to talk about their experience.” Brock and Kibben’s partnership reflects a growing trend in the study of moral injury: collaboration between scholars and clergy members who aim to chronicle the unspeakable and to help people through it. Moral injury “does really bring together a lot of disciplines,” says psychologist Anna Harwood-Gross of Metiv, the Israel Psychotrauma Center in Jerusalem. “It’s rare to see articles written by chaplains and psychologists together.”

As COVID ravaged the planet from 2020 onward, moral injury research and inquiry took a distinct new turn. Health care workers spoke out about how rationing care was affecting them psychologically, and Dean and her colleagues Breanne Jacobs and Rita Manfredi, both at the George Washington University School of Medicine and Health Sciences, published a journal article that urged employers to monitor moral injury’s effects. “We need time, energy and intellectual capacity to make peace with those specters,” they wrote.

The moral injury Dean sees in health care often doesn’t stem from one-time, cataclysmic events. Many providers are suffering what she calls “death by a thousand cuts”—the constant, stultifying knowledge that they have to give people subpar care or none at all. “They think they suck. They think they’re inadequate,” says trauma surgeon Gregory Peck of New Jersey’s Rutgers Robert Wood Johnson Medical School. “No one’s putting their finger on ‘You don’t suck. This is moral injury you’re suffering.’” 

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But one sticking point with CBT is that it focuses on correcting clients’ distorted thought patterns. For people with moral injury who’ve experienced wrenching events that upend their entire value system, ethical distress is genuine, not the product of distorted thinking, Harwood-Gross says . If people with moral injury simply try to retrain their thoughts, they may be left unsatisfied and unhealed.

Therapies for PTSD can likewise fall short for morally injured patients, in Harwood-Gross’s experience. PTSD-focused approaches teach clients to adapt to traumatic triggers, such as fireworks that sound like gunshots, but this exposure approach doesn’t really help them resolve deep ethical conflicts. Effective moral injury counseling is “more about the processing,” Harwood-Gross says. “There has to be that movement: ‘How do I see it for what it is and, from there, develop something more meaningful?’ It’s a more spiritual approach.”

Recognizing moral injury’s unique challenges, psychologists such as Litz have been creating therapies that more directly address clients’ needs. Litz and other providers have pioneered a moral injury treatment called adaptive disclosure. Researchers at Australia’s La Trobe University and University of Queensland have developed a similar approach called pastoral narrative disclosure. The latter involves discussing moral issues with a chaplain or other spiritual adviser rather than a doctor.

These therapies stress the importance of moral reckoning. They encourage clients to accept uncomfortable truths: “I led that attack on Iraqi civilians”; “I sent that suffering patient home without treatment.” Then, with clients’ input, counselors can help them develop strategies for making amends or pursuing closure—say, apologizing to a family whose child they injured.

Early evidence suggests these approaches make headway where others can’t. In Litz’s initial trial of adaptive disclosure on 44 Marines, participants’ negative beliefs about both themselves and the world diminished. Most also said the therapy helped resolve their moral struggles.

The article is here.

More than a quarter of U.S. adults say they’re so stressed they can’t function

American Psychological Association

Press Release

Originally posted 19 OCT 22

Americans are struggling with multiple external stressors that are out of their personal control, with 27% reporting that most days they are so stressed they cannot function, according to a poll conducted for the American Psychological Association.

A majority of adults cited inflation (83%), violence and crime (75%), the current political climate (66%), and the racial climate (62%) as significant sources of stress.

The nationwide survey, fielded by The Harris Poll on behalf of APA, revealed that 70% of adults reported they do not think people in the government care about them, and 64% said they felt their rights are under attack. Further, nearly half of adults (45%) said they do not feel protected by the laws in the United States. More than a third (38%) said the state of the nation has made them consider moving to a different country.

More than three-quarters of adults (76%) said that the future of our nation is a significant source of stress in their lives, while 68% said this is the lowest point in our nation’s history that they can remember.

Various disparities in stressors emerged among population subgroups. For example, 72% of the members of the LGBTQIA+ community reported feeling as if their rights are under attack, which is a higher proportion than non-LGBTQIA+ adults (64%). Younger adult women (ages 18 to 34) were more likely to report that most days their stress is completely overwhelming, in comparison with older women (62% vs. 48% 35–44; 27% 45–64; 9% 65+) and men ages 35 or older (62% vs. 48% 35–44; 21% 45–64; 8% 65+). Seventy-five percent of Black adults said that the racial climate in the U.S. is a significant source of stress, while 70% of Latino/a adults, 69% of Asian adults and 56% of white adults reported the same.

Furthermore, Latinas were most likely, among racial/ethnic groups, to cite significant sources of stress related to violence, including violence and crime (89% Latinas; 80% Black women; 79% Asian women; 77% Latinos; 75% Black men; 73% white women; 72% white men; 70% Asian men), mass shootings (89% Latinas; 78% Latinos; 77% Black women; 77% Asian women; 73% white women; 71% Black men; 67% Asian men; 66% white men) and gun violence (87% Latinas; 83% Black women; 77% Asian women; 76% Latinos; 75% Black men; 69% white women; 68% white men; 63% Asian men).

“It’s clear that the impacts of uncontrollable stressors are profound for most Americans, but psychological science shows us that there are effective ways to talk about and cope with this type of stress,” said Arthur C. Evans Jr., PhD, APA’s chief executive officer. “Focusing on accomplishing goals that are in our control can help prevent our minds from getting overwhelmed by the many uncertainties in life. From using our breathing to slow racing thoughts, to intentionally limiting our social media consumption, or exercising our right to vote, action can be extremely empowering.”

Adults reported that stress has had an impact on their health; 76% of adults reported they had experienced at least one symptom in the last month as a result of stress—such as headache (38%), fatigue (35%), feeling nervous or anxious (34%) and feeling depressed or sad (33%). Seven in 10 adults (72%) experienced additional symptoms in the last month, including feeling overwhelmed (33%), experiencing changes in sleeping habits (32%), and/or worrying constantly (30%).

The pressor is here.

Ethical considerations for precision psychiatry: A roadmap for research and clinical practice

Fusar-Poli, P., Manchia, M., et al. (2022, October). 

European Neuropsychopharmacology, 63, 17–34.

https://doi.org/10.1016/j.euroneuro.2022.08.001

Abstract

Precision psychiatry is an emerging field with transformative opportunities for mental health. However, the use of clinical prediction models carries unprecedented ethical challenges, which must be addressed before accessing the potential benefits of precision psychiatry. This critical review covers multidisciplinary areas, including psychiatry, ethics, statistics and machine-learning, healthcare and academia, as well as input from people with lived experience of mental disorders, their family, and carers. We aimed to identify core ethical considerations for precision psychiatry and mitigate concerns by designing a roadmap for research and clinical practice. We identified priorities: learning from somatic medicine; identifying precision psychiatry use cases; enhancing transparency and generalizability; fostering implementation; promoting mental health literacy; communicating risk estimates; data protection and privacy; and fostering the equitable distribution of mental health care. We hope this blueprint will advance research and practice and enable people with mental health problems to benefit from precision psychiatry.

From the Results section

3.1. Ethics of precision psychiatry: Key concepts

Broadly speaking, ethical issues concern the development of ‘practical ought claims’ (Sheehan and Dunn, 2013) (i.e. normative claims that are practical in nature), which arise when we face ethical uncertainty in precision psychiatry. These practical claims come schematically like this: how should somebody or a group of people act in relation to a particular issue when they face certain circumstances? For example, how should researchers inform patients about their individualised risk estimates after running a novel clinical prediction model? To address these questions, four overarching ethical principles have been suggested (by Beauchamp and Childress) (Beauchamp and Childress, 2019), which include autonomy, beneficence, non-maleficence and justice. These can be applied to precision psychiatry, complemented by an extra principle of “explainability/interpretability” (Panel 1) which has been specifically introduced for artificial intelligence (Floridi et al., 2018) (for a more detailed discussion of ethical platforms for big data analytics see eSupplementary 1).

Although these four principles have become the cornerstones of biomedical ethics in healthcare practice, they have been criticised as they are often conflicting with no clear hierarchy and are not very specific (i.e. these principles are somewhat implicit, representing general moral values), leading to “imprecise ethics” that may not fit the needs of precision psychiatry (Table 1). Rather we should ask ourselves “why” a certain act may be harmful or beneficial. For example, let's imagine having a risk assessment; what would that mean for the individual, their family planning, workplace, choosing their studies, or their period of life? Alternatively, let's imagine that the risk assessment is not performed; what would be the results in a few years’ time? To address these sorts of questions, this study will consider ethical values in a broader sense, for example, by taking into account some of the different principles present in the charter of fundamental rights of the European Union – starting from dignity, freedom, equality, solidarity, citizens’ rights and justice (Table 1) (European Union, 2012; Hallinan, 2021). In particular, human dignity and human flourishing are the most crucial elements from an ethical point of view that are tightly linked to autonomy and self-determination (which is modulated by several factors such as physical health, psychological state, sociocultural environment, as well as values and beliefs). The loss of insight associated with some psychiatric disorders may incapacitate the individual to make autonomous decisions. For example, autonomy emerged as the driving decision component for undergoing risk prediction testing among young populations (Mantell et al., 2021a), regardless of whether a person would decide for or against risk profiling. Finally, it is important to highlight that unique ethical considerations may be associated with the historically complex socio-political perceptions and attitudes towards severe mental disorders and psychiatry (Ball et al., 2020a; Manchia et al., 2020a).

The info is here.

Advancing theorizing about fast-and-slow thinking

De Neys, W. (2022). 

Behavioral and Brain Sciences, 1-68. 

doi:10.1017/S0140525X2200142X

Abstract

Human reasoning is often conceived as an interplay between a more intuitive and deliberate thought process. In the last 50 years, influential fast-and-slow dual process models that capitalize on this distinction have been used to account for numerous phenomena—from logical reasoning biases, over prosocial behavior, to moral decision-making. The present paper clarifies that despite the popularity, critical assumptions are poorly conceived. My critique focuses on two interconnected foundational issues: the exclusivity and switch feature. The exclusivity feature refers to the tendency to conceive intuition and deliberation as generating unique responses such that one type of response is assumed to be beyond the capability of the fast-intuitive processing mode. I review the empirical evidence in key fields and show that there is no solid ground for such exclusivity. The switch feature concerns the mechanism by which a reasoner can decide to shift between more intuitive and deliberate processing. I present an overview of leading switch accounts and show that they are conceptually problematic—precisely because they presuppose exclusivity. I build on these insights to sketch the groundwork for a more viable dual process architecture and illustrate how it can set a new research agenda to advance the field in the coming years.

Conclusion

In the last 50 years dual process models of thinking have moved to the center stage in research on human reasoning. These models have been instrumental for the initial exploration of human thinking in the cognitive sciences and related fields (Chater, 2018; De Neys, 2021). However, it is time to rethink foundational assumptions. Traditional dual process models have typically conceived intuition and deliberation as generating unique responses such that one type of response is exclusively tied to deliberation and is assumed to be beyond the reach of the intuitive system. I reviewed empirical evidence from key dual process applications that argued against this exclusivity feature. I also showed how exclusivity leads to conceptual complications when trying to explain how a reasoner switches between intuitive and deliberate reasoning. To avoid these complications, I sketched an elementary non-exclusive working model in which it is the activation strength of competing intuitions within System 1 that determines System 2 engagement. 

It will be clear that the working model is a starting point that will need to be further developed and specified. However, by avoiding the conceptual paradoxes that plague the traditional model, it presents a more viable basic architecture that can serve as theoretical groundwork to build future dual process models in various fields. In addition, it should at the very least force dual process theorists to specify more explicitly how they address the switch issue. In the absence of such specification, dual process models might continue to provide an appealing narrative but will do little to advance our understanding of the interaction between intuitive and deliberate— fast and slow—thinking. It is in this sense that I hope that the present paper can help to sketch the building blocks of a more judicious dual process future. 

A pdf is here.

Sexuality Training in Counseling Psychology: A Mixed-Methods Study of Student Perspectives

Abbott, D. M., Vargas, J. E., & Santiago, H. J. (2022).

Journal of Counseling Psychology. 

Advance online publication.

https://doi.org/10.1037/cou0000641

Abstract

Counseling psychologists are a cogent fit to lead the movement toward a sex-positive professional psychology (Burnes et al., 2017a). Though centralizing training in human sexuality (HS; Mollen & Abbott, 2021) and sexual and reproductive health (Grzanka & Frantell, 2017) is congruent with counseling psychologists’ values, training programs rarely require or integrate comprehensive sexuality training for their students (Mollen et al., 2020). We employed a critical mixed-methods design in the interest of centering the missing voices of doctoral-level graduate students in counseling psychology in the discussion of the importance of human sexuality competence for counseling psychologists. Using focus groups to ascertain students’ perspectives on their human sexuality training (HST) in counseling psychology, responses yielded five themes: (a) HST is integral to counseling psychology training, (b) few opportunities to gain human sexuality competence, (c) inconsistent training and self-directed learning, (d) varying levels of human sexuality comfort and competence, and (e) desire for integration of HST. Survey responses suggested students were trained on the vast majority of human sexuality topics at low levels, consistent with prior studies surveying training directors in counseling psychology and at internship training sites (Abbott et al., 2021; Mollen et al., 2020). Taken together, results suggested students see HST as aligned with the social justice emphasis in counseling psychology but found their current training was inconsistent, incidental rather than intentional, and lacked depth. Recommendations, contextualized within counseling psychology values, are offered to increase opportunities for and strengthen HST in counseling psychology training programs. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Impact Statement

The present study suggests that counseling psychology graduate students perceive human sexuality training (HST) as valuable to their professional development and congruent with counseling psychology values. Findings support the integration of consistent, comprehensive, sex-positive HST in doctoral counseling psychology training programs. 

Conclusion

Comprehensive training in human sexuality represents a notable omission from counseling psychology training, particularly in light of the discipline’s values including emphases on diversity, social justice, and contextual, holistic perspectives. In the present study, the first to explore counseling psychology student perceptions of sexuality training, participants outlined the importance of HST to counseling psychology training, specifically, and providing psychotherapeutic services, broadly, outlined the current nature of their training, or lack thereof, and conveyed their desire for HST including recommendations for how programs may successfully implement HST in ways that benefitted students and the public they serve. Therefore, we call on faculty in counseling psychology training programs to reevaluate their commitment to developing sexuality competence among their students, invest in their own sexuality training as needed, and invoke creative strategies to make HST accessible and comprehensive in their programs.

“Everybody’s doing it”: Exploring the consequences of intergroup contact norms

Boss, H., Buliga, E., & MacInnis, C. C. (2022). 

Group Processes & Intergroup Relations.

https://doi.org/10.1177/13684302221106926

Abstract

Newcomers to a country can strongly benefit from having positive intergroup contact with host country residents. Often, however, such contact does not occur. Norms surrounding intergroup contact between newcomers and host country residents were explored over three studies. Correlational relationships among positive perceived contact norms, positive attitudes, and behavioural intentions supporting contact were demonstrated over multiple studies. Further, an experimental manipulation indicating higher (vs. lower and control) contact between host country residents and newcomers predicted behavioural intentions toward future intergroup contact through heightened intergroup contact norms and more positive attitudes toward newcomers. Implications of using norms as a means to impact intergroup relations are discussed.

From General Discussion

Across studies, we demonstrated that perceived norms surrounding contact between Canadians and newcomers can influence attitudes toward newcomers, and one’s willingness to engage in contact with them. These findings are consistent with the theory of planned behaviour (Ajzen, 1991), such that perceived ingroup norms and attitudes are important predictors of behavioural intentions. Our findings were also consistent with group norms theory (Sherif & Sherif, 1953), such that perceived norms were strong predictors of attitudes toward newcomers. A manipulation involving reading a single newspaper article had clear implications for the perceived norms of participants in Studies 2–3. This has implications for discussions of newcomers in the media. For example, newcomer-serving organizations seeking to attract volunteers should be careful with how requests are framed. Projecting perceptions of ingroup disinterest in or disengagement from outgroups may damage attitudes and contact intentions among individuals who might otherwise be desired volunteers. As such, it may be ideal for newcomer-serving agencies to focus on the contact that is occurring rather than on the lack of contact when seeking to attract new volunteers.

Conclusion

We provide evidence that perceived social norms surrounding contact between ingroup and outgroup members can play an important role in attitudes toward outgroups and intentions to interact with these individuals in the future. Our findings are specific to the context of contact between Canadians and newcomers to Canada but may generalize to similar contexts. Our findings suggest that norm-based interventions can be a means to promote positive intergroup relations. Promoting positive norms about intergroup contact to the dominant group may be a valuable tool for increasing contact with newcomers, an important outcome given that intergroup contact can facilitate positive integration for new immigrants and refugees.

The research is here.

The Age Trajectory of Happiness

Kratz, F., & Brüderl, J. (2021, April 18).

https://doi.org/10.31234/osf.io/d8f2z

Abstract

A large interdisciplinary literature on the relationship between age and subjective well-being (happiness) has produced very mixed evidence. Virtually every conceivable age-happiness trajectory has been supported by empirical evidence and theoretical arguments. Sceptics may conclude that the social science of happiness can only produce arbitrary results. In this paper we argue that this conclusion is premature. Instead, the methodological toolbox that has been developed by the modern literature on causal inference gives scholars everything they need to arrive at valid conclusions: the causal inference toolbox only must be applied by happiness researchers. We identify four potential sources of bias that may distort the assessment of the age-happiness relationship. By causal reasoning we derive a model specification that avoids these  biases.  For  an  empirical  illustration,  we  use  the  longest  running  panel  study  with information on happiness, the German Socio-Economic Panel (1984-2017; N persons=70,922; N person-years =565,703). With these data we demonstrate the relevance of the four biases and how combinations of different biases can reproduce almost any finding from the literature. Most biases tend to produce a spuriously U-shaped age trajectory, the most prominent finding from the literature. In contrast, with our specification we find a (nearly monotonic) declining age-happiness trajectory.

Summary and Conclusions

How aging affects happiness is an important research question for the social and behavioral sciences. Our literature review demonstrates that many conflicting age trajectories have been reported in the literature. As this state of research is quite unsettling for the science of happiness, we  discuss—informed  by  recent  advances  in  the  methodology  of  causal  analysis—model specifications used by researchers in this field. Altogether, we identify four main biases that may distort the age trajectory of happiness. By using the German SOEP data, we show that distortions may be huge producing even qualitatively different conclusions. We demonstrate that by using different combinations of mis-specifications it is possible to generate (almost) every trajectory that has been reported in the literature. With a model specification that avoids these four biases, we find an age-happiness trajectory that declines slowly over adulthood (altogether about half a scale point). The decline comes to a halt and we observe even a small increase (about one tenth of a scale point) during the golden ages. Afterwards, in old age a very steep decline in happiness sets in.

The research is here.

Technology and moral change: the transformation of truth and trust

Danaher, J., Sætra, H.S. 

Ethics Inf Technol 24, 35 (2022).

https://doi.org/10.1007/s10676-022-09661-y

Abstract

Technologies can have profound effects on social moral systems. Is there any way to systematically investigate and anticipate these potential effects? This paper aims to contribute to this emerging field on inquiry through a case study method. It focuses on two core human values—truth and trust—describes their structural properties and conceptualisations, and then considers various mechanisms through which technology is changing and can change our perspective on those values. In brief, the paper argues that technology is transforming these values by changing the costs/benefits of accessing them; allowing us to substitute those values for other, closely-related ones; increasing their perceived scarcity/abundance; and disrupting traditional value-gatekeepers. This has implications for how we study other, technologically-mediated, value changes.

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Conclusion: lessons learned

Having examined our two case studies, it remains to consider whether or not there are similarities in how technology affects trust and truth, and if there are general lessons to be learned here about how technology may impact values in the future.

The two values we have considered are structurally similar and interrelated. They are both intrinsically and instrumentally valuable. They are both epistemic and practical in nature: we value truth and trust (at least in part) because they give us access to knowledge and help us to resolve the decision problems we face on a daily basis. We also see, in both case studies, similar mechanisms of value change at work. The most interesting, to our minds, are the following:

• Technology changes the costs associated with accessing certain values, making them less or more important as a result Digital disinformation technology increases the cost of finding out the truth, but reduces the cost of finding and reinforcing a shared identity community; reliable AI and robotics gives us an (often cheaper and more efficient) substitute for trust in humans, while still giving us access to useful cognitive, emotional and physical assistance.

• Technology makes it easier, or more attractive to trade off or substitute some values against others Digital disinformation technology allows us to obviate the need for finding out the truth and focus on other values instead; reliable machines allow us to substitute the value of reliability for the value of trust. This is a function of the plural nature of values, their scarcity, and the changing cost structure of values caused by technology.

• Technology can make some values seem more scarce (rare, difficult to obtain), thereby increasing their perceived intrinsic value Digital disinformation makes truth more elusive, thereby increasing its perceived value which, in turn, encourages some moral communities to increase their fixation on it; robots and AI make trust in humans less instrumentally necessary, thereby increasing the expressive value of trust in others.

• Technology can disrupt power networks, thereby altering the social gatekeepers to value to the extent that we still care about truth, digital disinformation increases the power of the epistemic elites that can help us to access the truth; trust-free or trust-alternative technologies can disrupt the power of traditional trusted third parties (professionals, experts etc.) and redistribute power onto technology or a technological elite.

The info is here.