Moral Injury Support Network Podcast
Join us as we embark on a powerful journey, exploring the often-unspoken challenges faced by servicewomen and the moral injuries they endure in the line of duty.
Moral Injury Support Network for Servicewomen, Inc. (MISNS) is a dedicated non-profit organization on a mission to bring together healthcare practitioners, experts, and advocates to raise awareness about moral injury among servicewomen. Our podcast serves as a platform for servicewomen and those who support them to share their stories, experiences, and insights into the profound impact of moral injury.
In each episode, we'll engage in heartfelt conversations with servicewomen, mental health professionals, military leaders, and individuals who have witnessed the toll of moral injury firsthand. Through their stories, we aim to shed light on the unique struggles faced by servicewomen and the transformative journey towards healing and resilience.
Discover the complexities of moral injury within the military context, exploring the ethical dilemmas, moral conflicts, and the deep emotional wounds that servicewomen may encounter. Gain a deeper understanding of the societal, cultural, and systemic factors that contribute to moral distress within the military community.
Our podcast serves as a safe space for servicewomen to share their experiences, find support, and foster a sense of community. We also aim to equip healthcare practitioners with the knowledge and tools to recognize, address, and support those affected by moral injury. Join us as we explore evidence-based interventions, therapeutic approaches, and self-care practices designed to promote healing and well-being.
MISNS invites you to be a part of a movement that seeks to create a more compassionate and supportive environment for servicewomen. By amplifying their voices and promoting understanding, we strive to foster positive change within the military and healthcare systems.
Whether you are a servicewoman, a healthcare professional, a veteran, or simply passionate about supporting those who have served, this podcast offers valuable insights and perspectives. Together, let's forge a path towards healing, resilience, and empowerment.
Subscribe to Moral Injury Support Network Podcast today and join us in honoring the sacrifices of servicewomen while working towards a future where their well-being and resilience are at the forefront of our collective consciousness.
Moral Injury Support Network Podcast
The Cost of Care and the Road to Recovery
When the weight of choice teeters between life and death, how does one find grounding in their decisions? Dr. Sarah Archer's voice trembles with the raw emotion of her time in Rwanda, post-genocide, as she maps the treacherous terrain of moral injury for us. Her candid recollection of reverse triage, the emotional toll it exacted, and her quest for solace through faith and service reverberate through the episode, offering a stark, humane look at the cost of crisis.
Our journey doesn't end there; we cross paths with a resilient 80-year-old former public health nurse who exemplifies the power of service and the potency of self-forgiveness. Her commitment to educating the next generation in public health, interwoven with personal redemption, unveils the silent battles many face as they transition from military to civilian life. As we dissect the complex web of social determinants of health and their role in moral injury, especially among veterans, we're reminded of the stark realities and the need for community and understanding.
Finally, we extend an open-hearted invitation to the upcoming retreat centered on addressing moral injury, discussing the poignant insights from a seasoned special operator. The conversation beckons leaders and those in service to join in solidarity to forge pathways of healing and to better support those carrying the unseen wounds of their professions. This episode is a call to arms for empathy, collaboration, and shared learning in our collective quest to alleviate the burden of moral injury.
All right well, welcome to today's Moral Injury Support Network for Servicewomen podcast. My name is Jamie Peer. I serve as the Senior Executive Officer for the Moral Injury Support Network for Servicewomen. On today's podcast we have Dr Daniel Roberts, our President and Founder of the Moral Injury Support Network, and we also have Dr Sarah Archer, who is currently serving as an adjunct professor at the School of Global Health for Indiana University. Dr Archer has her own story revolving around her moral injury experience and the work that she's done, dating back to the 60s, and so, without further ado, dr Archer, we have a lot of questions that we'll dig into that story, so I won't waste time. So, if you're okay, we'll get started.
Speaker 2:Okay, thank you very much and good morning everybody. It's a good day wherever you are. Thank you very much and good morning everybody. It's a good day wherever you are. It's a real pleasure to be here and to share my experience with you. For, whatever they may be worth, I developed more and so I'm just going to jump right in.
Speaker 2:I developed moral injury in 1994. And well, 1994, when I was the country director and medical coordinator for an emergency medical non-government organization in Rwanda as the genocide was ending. After that, at least 800,000 people had been killed and many, many more had been wounded and or fled, disappeared, displaced, had been wounded and or fled, disappeared, displaced. My organization's mission in Rwanda was to refurnish and reopen hospitals and their satellite clinics in areas assigned to us by the UN High Commission for Refugees, which happened to be the only authority in the country because the government had been destroyed completely. So we were UNHCR, put us all in places as they felt we were needed, and that was great. There wasn't anybody else to do it. We also were to train anybody we could recruit and convince to learn about primary health care, because the previous staff in these facilities were either dead or had fled the genocide, might come back but hadn't yet so because the killing was still going on, but not nearly at the level. Thank God that it was before.
Speaker 2:When I arrived in Kigali by a UN cargo plane, sitting on a bunch of bean sacks don't worry about seat belts we didn't have seats, and you don't on cargo planes, at least not civilian ones with $50,000 in US cash in my hand luggage, to get started on what we were doing, as I said, there was no government, there was no access to Rwanda by land at that point, so we were completely dependent upon UN air because, of course, the airport was out of commission, not destroyed but not working. There were no banks, there was no currency, there were no medical supplies, there wasn't much food which is why I was sitting on beans and not much of anything else except a whole lot of carnage. That was just unbelievable. Everybody's supply chain was dependent on UN air for all those reasons, coming in from Nairobi and Europe, and at the beginning none of us had adequate supplies or personnel to do in any means what needed to be done.
Speaker 2:There's endless need and demand of people who had for months been hiding in the bush with their wounds, some of which, well, I'll spare you graphic decisions. In addition to all of them, there were traumatized people in other ways there were pregnant women, there were infants, there were male nourished under five children and people suffering from trauma, untreated non-communicable diseases, aids, tuberculosis, etc. All of whom needed care that we, at this point, were really not able to give them. In the face of all this, as country director, therefore, I had to make a triage decision that, because of our limited supplies and personnel at the beginning, our mission required us to prioritize treatment to those people whom we could save. This country had seriously depleted population and we had to. And this is a reverse triage from what we're trained at here in the United States. We always train first to go for the most ill, the most seriously wounded, etc. Reverse triage is the absolute opposite of that.
Speaker 1:As a result.
Speaker 2:I realized that I made the decision and my staff somewhat grudgingly carried it out, but understood why. But I realized that because of my decision, some people were going to die prematurely because they were not going to get the care they need. This was absolutely clearly a morally injurious event, which is the ideology, essential ideology for moral injury. If you have not had PMIEs, you don't have mortal injury. This meant and this encounter with the PMIE forced me to violate my oath to do no harm. Health professionals take an oath to do no harm. Most of us take our oaths pretty seriously, but I had to do it and the circumstances were beyond my control, but I still had to do it. I could not rationalize or deny my way out of it. I rescinded the decision as soon as I could, when we had a reliable logistics chain, but by that time I did not realize at the time, but I do now I had moral injury because my grief and self-loathing and guilt for what I had had to do was quite apparent to me. I had violated not only my oath but my personal morals and my religious code. This is moral injury. I believe in a loving, just and forgiving triune, god. This helped me more than I think anything else did or could have to learn to live with my remorse for this decision. I returned to the United States in 1995. And because I had no name for what I felt, I said nothing about it. I couldn't describe it, I couldn't it didn't at that point have a name, at least not in the general public. So I said nothing about it and went about my business to do the best I could, and I learned to live with my guilt and to do my best. I had family issues which I had to deal with and I was working in community service organizations, so on.
Speaker 2:Fast forward to 1998, I was invited to volunteer as a role player and as an NGO role player in the capstone exercise at the Army's Command and General Staff College at Fort Leavenworth. All the majors who are possibly going to be promoted have to go through this course. So we had a very large, very interesting and great training audience. So my Vietnam Special Forces veteran handler, who had PTSD and moral injury as well as died from Agent Orange, just recently told me I was to do what I in the exercise, what I would do in the field, and so I did, which made me a real pain for those poor students. So I did, which made me a real pain for those poor students, but anyway, they were here, they were to learn and I was there to make it as difficult for them as possible and I did so. That was fine and I enjoyed it. Three months later, I had just come back from Kosovo for the same NGO.
Speaker 2:I went to Rwanda for this before the bombing started and there was a voicemail on my phone. Bitch call me. I said oh, it has to be him. So well, of course it was the kansas phone number. So I called him back and, um he, uh. He invited me uh to uh, urge me actually to uh go to work with them. They were deciding they were going to really have to use civilians. He says you were such a pain in the ass that we've decided to hire you. And I said, good, I intend to be even worse. And and he said that's what we figured. So we were off.
Speaker 2:And it turned out to be a great experience in many, many ways for the next 22 years. I got to talk to a whole lot of soldiers, sailors, airmen and Marines all over the world, and our troops, nato troops, african troops they all have it and when you start talking to them, you can hear about it. I still didn't know, remember, I still did not know what it was, what I had, what to call it, but I heard stories as we prepared military here in the United States for OEF, oif, s4k4, nato missions and our deployments and humanitarian and national disaster response deployments all over. I did more than 100 of those learned a lot in every one of them. More than 100 of those learned a lot in every one of them. Many of my contractor colleagues and students had PTSD. We learned from each other, we bonded, we talked about what happened to each other because I could say to them truthfully I know how you feel and this is essential and this is why many civilian people who try to help people with military or any fire people or health workers, if they don't understand what we do, why we do it and how we do it, it's very difficult for them, or it's more difficult for them to help us and also for us to accept that they really know what they're talking about. So I had street cred, for which I was very grateful, although it was painful. Rwanda popped up in my head all the time, but I was plenty busy enough not to let it bother me, which I was fortunate about. I'm pretty stubborn.
Speaker 2:Fast forward again to 2017. I finally discovered what I had and what so many of my military buddies had when I read Jonathan Shay's book Odessa in America Combat, trauma and the Trials of Homecoming. I have read it again. I have my students read it. I have the people I work with in the project I'll talk about later in North Carolina read it again. I have my students read it. I have the people I work with in the project I'll talk about later in North Carolina read it. They're also students. It is a marvelous book and very fun.
Speaker 2:Jonathan's one of the earliest person sealing with the VA, with PTSD and something he called complex PTSD. The complex part turns out to be has turned out now to be labeled more moral injury. So I finally had a name and I had a new mission. I could begin studying moral injury. I'm an academic sorry, I you know I didn't go to academia, but I'm an academic and right now a relapsing academic, but anyway. So I finally had a name and I got busy with it and I went to I had worked with because of my role. I worked all the time with civil affairs chaplains, medical personnel, planners, etc. But particularly the first three.
Speaker 2:And I happened to be going to an exercise at Fort Bragg right after I discovered Jonathan's book. So I ran around to these offices and said hey, let's have a meeting, I want to talk with you about moral injury. And some of them said what's that? And I said that's why I want to talk to you about moral injury. And others said, oh good, I realized somebody knew what I was hoping to talk about. So we had a great session. I had put together a handout. The commander did not come, but the chief did and he said finally, when he had to leave, he said I don't know what you people are doing, but I think you better keep on. And we did.
Speaker 2:And so from then on in I did discussions. I had a handout, I revised it, we worked on it together, I put it together and used it with every training audience, in every subsequent exercise for deployment or just ordinary, regular standard training with anybody who was interested, and so on. And I cannot tell you how many people walked up afterwards and said I didn't know what I had until you talked about it. And I said I understand that I, you know. For years I didn't know what I had, but anyway, now we have a name and you have to have a name to be able to really identify something and deal with it. That's a real first step. I kept on that, as I said, until 2020, and when I added working with here in the United States and in Kenya, where we have a big project from IU with moral injury, with medical school medical students and hospital personnel, as well as my own dissertation students who are over there, well as my own dissertation students who are over there In 2018, I'm jumping around in time in 2000,.
Speaker 2:This is how life goes In 2018, and the fact that I was 80, it became the flying, the hours, the so on were getting to be more than I could handle, and COVID was looming on the horizon and I knew this was going to be a pandemic. I haven't been a public health nurse for 64 years for nothing. So I needed to find a new mission. I'm emphasizing mission because, as far as I'm concerned, what kept me from losing my alleged mind is the fact that I had a mission, and when I sort of wore out one or went away, I found another one. People without missions die. As far as I'm concerned.
Speaker 2:Anyway, I figured I'd better get a new mission, and that was I've been asked before to join the Global School of Public Health here at IU and had said no, I'm too busy. And as I realized I was going to be going out of the military business, I said yeah, I'll do that. The travel restrictions of the pandemic sealed the deal. Because I had 80 at that time and underlying health conditions, I was not going to be traveling very much, particularly not outside of the United States. And I also joined the Building Veteran Healthy Communities, a VA project, a VA-funded project at the School of Public Health in North Carolina, of which I'll talk later. Unfortunately and inevitably, I was still having problems with moral injury, in spite of my mission and my trying to get away from it, and it haunted me, as moral injury does, and turned up at the damnedest times and the most inconvenient times, I mean when you need to be at your best. Bingo, there it is, and it just makes a mess of the whole thing. It is, and it just makes a mess of the whole thing. So I also discovered a new mission, which is this fine organization which I got involved with last year, and the culmination of this story is coming to, I'm sure your great relief.
Speaker 2:But on November 15th of 2023, I was working with Annette Hill, who was the other keynote speaker for our conference in September, which I hope you all will attend, and we were coordinating our two Keystone presentations. And I asked her I had seen a video of hers where she used the Responsibility Pie shrink yeah, sorry, a psychiatric tool. And we were talking about whether or not she was going to use a demonstration in her half of the keynote. And I said, well, I don't know anything about that and what is it? And she said this little sneaky clinician that she is. Well, let's do it on you and then you'll know. Let's do it on you and you'll, then you'll know. And I fell for it like a ton of bricks and so we did.
Speaker 2:And about what the process is and she'll talk about this more on Tuesday, when I, wednesday, after I've talked on Tuesday is that it's a. It's a pie, it's a pie chart, a blank pie chart when you start out. And what she asked me to do was systematically talk about each of the circumstances, events, the shooting down of the plane of the two presidents, et cetera, et cetera, and to put some sort of a percentage on that in terms of how was the situation that I got into had been created. And so I glibly started off and you know, yeah, this and this. And then, well, of course, there was an army and a militia, and they were killing people with machetes, right and left 800,000 of them, and so on and so forth and so forth. Shortening all of that, by the time she handed me the chart that she had diligently drawn while I was babbling away, 95% of the responsibility was already filled up, which left me with five.
Speaker 2:Well, and about that time, or about halfway through, I began to react physically, as one does, to moral injury. My face was flushing, I could see it, we were on Zoom, I was sweating, my voice was cracking to tears and, um, she, she said, you know, she. She handed me the again the chart, and I looked at it and she immediately said to me how do you feel? And without thinking, without a nanosecond of thought, it was a sheer reflex response I said one word liberated, and she said that's okay. And then she asked me what have you lost? Because many people with this kind of illness, apparently I'm told I didn't have it find some use in having this, getting sympathy, whatever. I never bothered with that, but what I did say was a weight off my shoulders, and then I added as an epiphany that I no longer had moral injury. It was gone, so it is curable.
Speaker 2:There's another takeaway, please. It is, it sounds crazy, but it happens. Just something as simple as what she did got me out of my emotional hell and straightened me out. Now the takeaways from this. I think and I want to emphasize these a belief in a merciful and forgiving God or some power greater than oneself is immensely helpful and supportive. Commitment to a mission to serve others is essential, and I believe that's why we are put here is to serve each other, is to serve each other. A willingness to consider risks reasonable risks, like going with the military when you get called a bitch before you start can help others, and by helping others we help ourselves.
Speaker 2:We inflicted moral injury on ourselves by what we did, what we thought, what we said, what we didn't do, what we saw others do and didn't report or stop, so that we have got to have a an active role in getting rid of it. We did it, we got to undo it. We be healed and we need to accept and be grateful for the help we've had on our journey and we must stop driving. People who have had and I now can say I have had, I do not have moral injury have got to stop driving our lives as if we were only looking in the rear view mirror. We have got to look at the future. And we have got to look at the future with a mission or their next mission, or a new mission or whatever, with hope and joy. And that's the end of that little sermon and that's the end of that little sermon.
Speaker 1:Well, Dr Archer-Sara, I just want to thank you so much for sharing your story. Very, very powerful experience, that a mission to keep going. Just in my own experience with moral injury, discovering the Moral Injury Support Network for Service Women isn't it interesting that the acronym is MISSIONS?
Speaker 2:No, it's not interesting, I know.
Speaker 1:It is interesting, but it's also intentional Right and by the Almighty.
Speaker 1:Yes, so. So I just wanted I would be remiss if I didn't express gratitude to Dr Roberts for starting this organization. It has given me a new purpose in helping facilitate things like this. I love that you met Annette through missions, and the fact that you're going to work together as the keynote speakers for the conference also created this opportunity for healing, and that is what this is all about is bringing people together to facilitate and accelerate healing. So, dan, do you have any thoughts? I just complimented you. You could just say thank you.
Speaker 3:That's amazing.
Speaker 3:I really appreciate saying that, though, because you know, in any endeavor you do, you know you have hopes and dreams for it. But but in the daily work of just like grinding it out every day, trying to make things happen, trying to grow an organization, trying to solve problems, pay bills, whatever it is, it can be easy to forget that it's about the people. It's about the folks, it's about making the world a better place and all that. And so when you hear that, you go, oh yes, this is what it's all about. And I keep in my email. I keep a folder called it's All Worth it. And when people send me emails whether through the military work or this mission work about hey, this saved my life or this was a huge thing, whatever, I put it in that folder. So on days when I'm like I can look back and go, oh yeah. So again, I echo Jamie's thoughts.
Speaker 3:I mean an amazing story, there's so much to it, as they say that'll preach. I mean that is a. It's just. There's so many great nuggets and I love how you, how you finished with.
Speaker 3:Here's some real takeaways that people I think so many people relate to bits and pieces of your story, even if they've never been a medical person, even if they've, you know, if they've been a soldier or something, there's a piece of it they go. They can just really sink their teeth into. What I'd like to do before I pass it back to you, jamie, is what I'd love for you to do, sarah, is to take everything that you just said from start to finish, put it in a nice Word document, send that to me and I want to include it as a chapter in Volume 3 that we're working on. So we publish a book each year or so that has moral injury, research, discussion, intervention, support methods in it, and you can add to that story, to a lot of other parts, because as long as you want to make it, we'll take it and we'll put it in volume three, because I think there's, you know, the story bits, the takeaways, the what do you call it? The pie, the responsibility pie.
Speaker 2:Yeah.
Speaker 3:All those pieces I want people to, so so, yeah, if you could just build all that in, add whatever parts of the story you want, doesn't matter how long it is Push that to me as a Word document. I'll build that into as a chapter to volume three because it's super powerful. So thank you so much sharing from the heart, just giving us the unvarnished truth and and and I appreciate that your decades and decades of experience we can all learn from. So thank you very much.
Speaker 1:Yes, thank you. So we're going to kind of move into current situation, you know, with your work as a public health academic, and so a lot of these questions are going to be along those lines. And this is you know, and just know that. You know everybody that's listening these are going to be just snippets of her experience, but, you know, coming to the conference you'll be able to have dinner with Dr Archer and ask her all the questions that you would love to ask her. Would love to ask her, yes, so I'll start with our first question.
Speaker 1:So, with your extensive background in public health and experience as a consultant on moral injury, how would you describe the relationship between the social determinants of health and moral injury? And I will. I want to admit upfront, I had we use that phrase a lot in our discussions, but I had to go do a little bit of research on what those were. So if you wouldn't mind helping those of us that may not be as spun up on what those social determinants are, but then how did? How do they interplay with moral injury and in what ways do you see these factors intersect and influence one another? So there's your question.
Speaker 2:Thank you. Yeah Well, since I had the questions in advance, I am prepared at least to give a try to answer. I'm going to be fairly academic about this, but I'm a relapsing academic. I've already told you that academic about this, but I'm a relapsing academic. I've already told you that Social determinants of health, or SDOH, which I probably will use from here on in, are broadly defined as the conditions in the places where people live, learn, work and play that affect a wide range of health and quality of life, risks and outcomes. Academic but pretty descriptive.
Speaker 2:Longstanding health inequities and poor health outcomes remain a pressing policy change needed here in the United States, as data from the pandemic have made painfully clear, with the differences in death rates of people who were smart enough to get vaccines and the people who refused. They are no longer with us, many of them. But amongst poverty about lower income folks, people of color who are understandably afraid of vaccines and healthcare because of their history with we white people in those professions. But anyway, that but research I can. I digress. I warned everybody about this. Studies in. I warned everybody about this. Studies estimate that clinical medical care your doc, my doc, the dentist, et cetera impact only 20% of community-level variation in health outcomes, while social determinants of health affect as much as 50%. This is why we harp on SDOHs. Social determinants of health include housing, food and nutrition, transportation, social and economic mobility, education, employment, mobility, education, employment. These are the social indicators that have been identified to have the largest impact on people's mental and physical health outcomes.
Speaker 2:For example, a veteran who's already self-deprecating due to moral injury and that's a serious symptom about it I'm no good, I'm a bad person, I don't belong to live, be here, I should have died. Survivors, guilt, etc. Are rejecting them, which increases the veteran's isolation and pain and reinforces his or her already serious self-deprecation, self-worth issues. Therefore, many veterans are reluctant to even reveal that they are veterans, which is one of the problems in trying to help veterans, which can compound issues for them when they really need help. On the other end of the spectrum, many civilians have had little experience with service members and veterans, since only 6% of the US adult population serves in the military, and so civilians and veterans may not and I propose, do not understand each other very well. Another issue is affordable housing. It's a problem for everybody in the country. Mortgage rates are up, building is slow because of the season and expensive material and so on, but it's a nationwide problem. It really threatens veterans, sorry.
Speaker 2:A report came out from DOD that the number of homeless veterans who were serviced by VA or the Department of Veterans Affairs in 2022 was the number was 35,574. And this was a 7% increase over the previous year. I have no idea what it is now, except that I would bank on the fact it is much worse and one homeless veteran is too many. Now. This background suggests that social indicators of health or social determinants of health and moral injury may often feed off each other into a negative and dangerous vicious cycle that makes veterans transition to civilian life, quality of life and survival Difficult and makes their MI worse. So there's the interplay that these factors that veterans don't really have much exposure to, as I'll talk about in a minute, can make their moral injury worse because it it affects them and their isolation, and so on.
Speaker 1:Yes, okay, well, that was a big part of my next question was how do these things affect veterans specifically? But I think you answered that beautifully, so my next question I'd like to add something, if I may. Sure, yes, please do.
Speaker 2:I've written this out. You made the mistake of giving me the question.
Speaker 2:No, you're totally fine For preparation. Many career veterans are children of military families. They went to military schools, they enrolled in ROTC and they enlisted in the service shortly after high school or college and then served a 20-year career or more. In short, the veterans have lived predominantly in a military bubble for much of their first four or five decades. So on retirement they suddenly enter society, society essentially for the first time, and it is not surprising to find that the social indicators of health and the complexity of this society leads to again this, this relationship between these, the downward cycle of moral injury, and I don't know what to do here. And there's too many, too many, too many. I mean I've talked to veterans Even something as simple and basic as going to the grocery store, I mean, at the commissary you have choices, but not six or seven and the big box grocery stores here and nobody wants to be making all these choices. I understand, having lived in Asia for nine years consecutively, I understand how difficult it is to come home Just because of the complexity, and this is extremely difficult for veterans.
Speaker 2:The real problem with this is suicide, because that's where moral injury ends, literally. Mine ended obviously otherwise, but too many people's moral injury ends in suicide and the military are trying to do things about suicide, but this is not easy. The suicide rate for our veterans and service members is one and a half times bigger and greater than in the civilian population. The sort of good news anything positive is good news is that the rate has decreased from 22 veterans a day committing suicide to 20.6 daily suicides. One veteran suicide is too much.
Speaker 2:The confluence of lack of experience with civilian life and its social determinants, of health Loss of their familiar and more predictable military, social and environmental milieu, and their loss of military mission. Military is all about mission and esprit de corps. I have never in my life, in 22 years I saw it the level of closeness that these guys and gals develop with each other, which makes combat so deadly for everybody, because you lose your friends, the government or the command, or circumstances lead you to do things you don't want to do and you feel betrayed, which is the other cause of moral injury what I did myself and being betrayed by people or institutions whom I trust and who have betrayed me. Our most recent example, large example, is the precipitous withdrawal from Afghanistan in 2021, leaving behind so many of the Afghan people who risked their lives and those of their families to help us and whom we promised to get out and save from the Taliban, and we did not.
Speaker 2:So a lot of people have moral injury exacerbated by things like that. We think of those sorts of things as something that's away and doesn't matter to us. That's in Afghanistan well, too bad. It's right here. It's your neighbor, it's your husband, it's your daughter, wife, it's your daughter.
Speaker 1:So that leads to my next question how can leaders within health care organizations, the VA and outside of the VA address moral injury and incorporate strategies to help mitigate its impact on individuals' well-being? Have you seen any specific leadership approaches or practices that have shown promise in this regard?
Speaker 2:I teach a 10-week course on leadership to public health leaders. So yeah, good ones and bad ones, and then there are obviously both. However, one of our first problems is that health care administrators, wherever they are, must first recognize that medical care, psychiatric care, nursing care, everybody's care is ubiquitously populated with potentially morally injurious events. We're exposed to them every day. We're exposed to them every day. The pandemic pushed this all out of proportion. Because we did such a lousy job of dealing with the pandemic, as our fatality rate shows, as our numbers of long-term COVID show, because people didn't get vaccinated. I mean, we who got vaccinated are still alive for the most part. Those who did not get vaccinated, for whatever reason, are either dead or have, if they contracted it, have long-term, will likely have long-term symptoms. And these potentially metamemorally injurious events all through healthcare hit everybody, from administrators to physicians, to clinicians, to technicians, to nursing staff, to housekeeping. Everybody is faced with these and we have got first to identify them and realize that they are there and then start carefully to look at them and do something, to do something about them. Some of them can be reduced, some of them are going to have to be lived with, and we have to, as the serenity prayer says know the difference. Serenity prayer says know the difference.
Speaker 2:Practice participative, transparent leadership a very rare commodity in most organizations. Treat staff as you want to be treated. Ask staff for recommendations and listen to them. Novel idea and act on what they recommend. If you possibly can, and if you can't explain to them why, don't just leave them hanging. Practice equity, equity.
Speaker 2:I get very tired of people who conflate equity and equality. They are not the same painfully. And equity means that you meet people's needs as they are, where they are, when they are. Equality is everybody gets the same. If you give everybody the same, you haven't done anything to help material. I mean significantly equity issues that so many of the people in this country, never mind the world, face every day.
Speaker 2:For example, the odds of burnout and the medical people. We use burnout too much and most of what. As I look at it, what they're talking about burnout. Burnout is exhaustion. I hate my job. I want to get out of here. Yuck Moral injury is I screwed up? I did something wrong, but this is. There's lots of moral injury, as I said, in medical care, some of it by mistake, some of it because of not sufficient PPE or medications or we screw up the medications and so on.
Speaker 2:Burnout, as they define it, is 50% of women.
Speaker 2:No, 50% more women experience those kinds of symptoms than men, and the workers of color are 30% more likely to intend to leave their jobs. So we have got to improve career developments and opportunities, salaries and benefits for women and people of color, who are the major component of our health care services. Staff, particularly in long-term care facilities, are particularly underpaid, overworked and unappreciated, and turnover is incredibly high, incredibly high. This results in real problems so that we need to look at free mental health counseling within the staff to deal with traumatized people and pay for it ourselves. This can improve morale and therefore the quality of care. Happy workers are good workers, are effective workers, are efficient workers who really want to help people and said I just want to get the hell out of here. The CFOs and the financial folk will immediately veto this because it will cost too much. We need to remind them that the cost, the estimated cost of turnover in the United States in healthcare right now is $4 billion a year, so we've got some money to play with. I would suggest.
Speaker 1:Okay, so I have two more questions for you before we wrap up our podcast today, and I think the one of the one of the things that you and I have talked about, dr Archer, is at least in my own experience is you come into these situations and what is told to you is it's about duty, honor, country, it's about doing no harm, it's you know, so we're we're kind of set up for moral injury and that we expect these values to be adhered to.
Speaker 1:But the reality on the ground is so much grayer than that, and having that heads up, I guess, is what you call anticipatory guidance. Right, like knowing that, and this is hard. You talk about the age of people that come into the military, or even just young medical professionals coming out of college for the first time, where all these values have been espoused for nearly a decade, and then the reality is something else. Nearly a decade, and then the reality is something else. Can you talk about what sorts of anticipatory guidance you would recommend to help promote resiliency and address moral injury in these various settings?
Speaker 2:I can try anyway at least. I'm a public health person. I believe my my raison d'etre again is prevention. I believe by the time people get to the hospital, it's because we have failed in the community, in the government, in the health professions and so on. We should be able to stop some of this stuff, and we know we have the knowledge and the ability to do that, but we don't do it. Part of it is people don't want to do it, but we've got to find ways to help them do it. So a public health mantra is it's better to prevent than to have to treat, and anticipatory guidance, or preventive counseling, as we call it.
Speaker 2:Guidance, or preventive counseling, as we call it, enables people, as you said, to know what's coming. It really is to keep people from being blindsided, because we tend to react immediately to something, to a surprise or to a blindside event. Emotionally, our animal brain takes over event. Emotionally, our animal brain takes over our frontal lobes, which are our reasoning and decision-making, go to sleep or cut off, actually, because the animal thing is so busy, busy, busy, and so we either fight, flee or freeze, which in the case of a shooter may be useful, but in most places is not. We need to be able to reason through these things. But if we were just able to understand that life is not a bowl of cherries there's pits and they'll break your teeth Not nice and they don't taste good either. That we have to begin to help people to look forward again not the rear view mirror, but look forward, but to realize that not all is going to go as well as you planned and there are real problems coming along.
Speaker 2:Guidance right now is by pediatricians in helping them to help families, parents, new parents up to 17 year old, which is pretty, then tired parents by then to understand why their kids are doing what they're doing and what's normal and what's abnormal and what the heck to do about it. Because the second mantra is if you can't prevent it, you better find it early and do something about it when you get rid of the primal cause, prevent it or get it early and mitigate it, as you suggested. Now a couple of we we do. I have used this for years. Well, my clinical experience is in in uh, maternal child health and, and I've used it with parent expectant parents for years. But some of the feedback I got I wasn't scared when the baby dropped and I had to go to the bathroom all the time. It was normal. I knew that. You told me Okay, this is expectant mother, obviously, or that's one of the problems.
Speaker 2:You know, I think I know what I'm talking about. Don't necessarily make it clear, and we do that to each other all the time, and so you need feedback, just like she gave me. Like you know, you're not being clear on this. Thank you very much. Another one was. This one will be clear, I think that. Thanks for advising me to cover up my son when changing him, so he doesn't pee in my face.
Speaker 1:Oh wow that happened.
Speaker 2:So anticipatory guidance can help in a lot of situations. Let me tell you one I tried with the Army. Well, anyway, between 2017 and 2020, when I left DOD I proposed anticipatory guidance to senior NCOs getting their troops ready to go to all sorts of places where I knew they were going to get shot up, asking them to have group discussions with the troops about what they were likely to experience in combat before they get to combat. This is important for all troops but, as you indicated, it's essential for kids under 25. Our brains, our frontal lobes, do not mature completely perhaps some of us ever, but for all of us much before we're 25. And think of the age distribution of our service people. We got a lot of people under 25 and some of them still in their teens, so that we really need to help those folks because they are not prepared Maybe we know none of us are, but they are even less prepared than the rest of us to take on the emotional and mental reactions that they're going to have when they see someone killed or kill someone themselves or their buddy is killed or their vehicle is ID'd, and half of them are dead and the other half are wounded. I mean they can't deal with this None of us could. But at least if they knew this might happen, they might be able to better cope with it on the spot, which is essential to save their own lives. But also later, when they start thinking about it in the middle of the night, when it comes back as a nightmare. This is called PTSD. So, and it can also most of us don't have well MI. People can have nightmares too.
Speaker 2:Well, when I talked about this with the senior NCOs, shall I say they were not overly enthusiastic about this. With the senior NCOs, shall I say they were not overly enthusiastic. Some of them I mean some of them just looked at me like you know God, we know you're from another planet and you should go back. But others said to me things like if I do that, they'll never go, and I said they don't have any choice. I said they have to go. So you really need to do this. Well, it'll undermine morale. And I said so what happens to them? I didn't get very far with that. So I switched to the second mantra, which is in public health, at early detection and prompt intervention, and I asked the NCOs to be alert when the troops returned. This is after the fact. We've lost the possibility of preventing this.
Speaker 2:Now we got to deal with it, return from the mission, especially if there'd been casualties or, worse yet, fatalities, and to be extra observant again to the under 25s. If it doesn't look normal, find out why. Get them in a group when they come back. I mean, let them go to chow, maybe, or even do this at chow um. Get them in a group to talk about this, to air their feelings, to get them out, so that they don't internalize them, which will leave them inside of them to fester, and the sooner we do this the better.
Speaker 2:It's called talk therapy. I mean, it's much more sophisticated when you go to your shrink's office, but this is basically a talk therapy Get it out. Get it out where you can look at it and in a group, because everybody's had the same experience, so that I don't feel I'm the only one. But I don't feel I'm the only one, and I know I have other people I can talk to who understand and have shared this experience and are going to be able to accept me without saying you did that, which is a civilian reaction that I've seen happen, and this is so important.
Speaker 1:That's very interesting, one of the things that my husband and I have talked about. We're both military history nerds and, of course, one of the big differences you know, I imagine I wasn't there, but um, as as units and troops were coming back from world war ii, they were on boats and they had lots of time to process and talk and build relationships. But Vietnam they were coming back as individuals and just trying to assimilate with no ability to process, nobody really understood, people were attacking them. That compounded their moral injury, probably exponentially. But not to get on another topic, I, just, before we wrap this up, I want to give Dan an opportunity to. I love asking questions, so I'll give Dan an opportunity to kind of wrap up any questions he might have. And then the last thing I'd like to ask is there, is there anything that you would love the audience to know? And and also just another reminder that you're going to be at our Comprehensive Moral Injury Conference, sharing the keynote with Annette Hill. But, dan, you have anything?
Speaker 3:Yeah, so thank you. I think it's interesting the participatory guidance to combat soldiers, and I feel the same way. I think I can easily see how they would think we can't tell them that they're not going to want to go. It's going to change their morale, whatever. I recently became friends with a special operator. He has been out of. He's been in the army for over 20 years. He's actually been deployed for 18 years total. I mean, he's elite of the elite, personally responsible for the death of over 4,000 people, both close to close combat, you know, face to face, five feet apart, and using drone strikes, artillery and everything else. So he's been a death dealer for a very long time and, of course, now he's struggling with a lot of post-traumatic things.
Speaker 3:But one of the things that he does a great job of is talking about what it's like. I mean, he's been doing combat for as long as most of these young men and women have been alive, and so he's able to have that anticipatory guidance in a way that I think they can hear and leaders can hear, and it's super valuable. I agree that it should be done and I think one way we can go about doing that and I've talked to him and asked him to share with us. He's not ready to do that, but he will. He will talk to other soldiers, and so there is, there is a way to do it, and I agree it's absolutely vital.
Speaker 3:He has an interesting way that he goes about it, in that he he explains. You know, what you'll feel at the moment is nothing, because you're trained to do this, but later, this is what I felt, this is what I experienced, this is how, the longer that I was doing combat operations, the more disconnected I became to my spouse my spouse and then, as he had young children, it became even worse, because there were times that he was personally responsible for the death of young children, and then so it created this huge emotional gap between him and his spouse and children that he really struggled to bridge.
Speaker 3:And one example was he said, you know, early on in the war they didn't have the kind of communication they had. But he said later on, as he would, he could sit in his office basically eat lunch and watch drone strikes and artillery strikes and all that stuff. He had multiple phones, multiple ways of communicating. He could actually pick up the phone every day if he wanted to and talk to his wife and kids, but he didn't talk. He went weeks without talking to him because every time he thought about doing that it was like revisiting all this, you know inner conflict with what he was doing, the person he had become and, you know, his family back home.
Speaker 3:Now he did become a strong believer and his faith was hugely instrumental in helping him through all these things, instrumental in helping him through all these things. And he believes and he operates as both. He can be both a Christian and a warrior but you know he's able to kind of work through those things. But he also has a behavioral health specialist. He sees, he has a chaplain that he sees all this stuff. So I think those kind of conversations can be had. I think it's often about matching the audience with the voice. You know and I think you're a great voice, I think you did a great job but sometimes you know, as military leaders, they're just not open to hearing from people that aren't them.
Speaker 2:But if you can get them to have those conversations, I think it can be really huge.
Speaker 3:So anyway, I'll turn it back over to Jamie at the end. I do want to have a few ending words, but I appreciate all the all that you said, and I think there's a lot more that we can continue to do as a, as a community, as a nation, to to support folks that are doing things that, like you said, civilians really don't want to know about, because if they did, then they could be morally injured on some level.
Speaker 2:Right, it's contagious.
Speaker 3:Yeah, absolutely so. Anyway, back to you, jamie, thanks.
Speaker 1:Well, and I think that is as you were saying that, dan, I was thinking that is another benefit of having a support network, not just for the people that are experiencing moral injury but for those of us that are endeavoring to help them with their healing. You know, maybe somebody is not receptive to Sarah, but the person that's that they are receptive to could learn from Sarah and incorporate her knowledge into that exchange and by you know, vicariously, sarah is helping that person and that is what's so beautiful about the work that we're creating with the Comprehensive Moral Injury Conference is, you know, missions is dedicated to helping service women, but we are part of a larger network of professionals endeavoring to help people with moral injury and we all have these specific niches. But what are you learning in your niche that we can then apply to our niche? And that collaboration, I think, is going to. It's so important. Like Sarah, I know you.
Speaker 1:We talk about the silos right, and we talk about everybody's kind of operating in their own. Well, I help these people and I help these people. Well, what are you learning in those silos and how can we break down the silos and bring them together as a cooperative right? Everybody brings their, their goodness to the cooperative. So I just love that. So with that, um, is there any final thoughts that you have, sarah? Um, you know, any encouragement that you can give to people in the public health space on why they may want to attend the comprehensive moral injury conference beyond what I just said, go ahead.
Speaker 2:Well, it's not just the public health space, I think it's clerical, I think it's social work, I think it's all of us in the so-called helping professions, which sometimes are not as helpful as we wish they were. But we don't talk to each other and there's an amazing amount of information that we can share and that needs to be shared. And the reason that we've got to do this, and we've got to do it quickly, is 20-some people a day are dying because we are not doing this, and that's just one subgroup. Who knows Out of which silo information will come about other groups that are also having issues, substance abuse users, which are not obviously necessarily military, and it. One of the things that has always disturbed me, and and continues to, is that the gap between what we know and what we do, or what we implement and how we evaluate it and what we learn from it.
Speaker 2:Now the buzzword is evidence-based practice. Well, okay, that sounds awfully nice. I'm not a very nice academic at least my academic people think. Students don't think I'm so bad. But you know, we have got to do more of this, not just because it's right, but because people are dying because we're not doing it, and I don't mean to make people feel guilty. But a little guilt sometimes isn't too bad, it works. It does work and it does motivate.
Speaker 2:And this is the thing, and particularly with our veterans. I mean look at these guys I've seen and gals, and particularly with our veterans. I mean look at these guys I've seen and gals and mostly I keep saying men, not because I'm discriminating but because I've worked with combat troops and there weren't many of those years with many women in those units. Those who were had a whole different set of problems, but we'll talk about those some other time. But these folks have done so much for us we would not be free. We owe our freedom to our military and you know we are and the sacrifices that I see and hear about that the families make Dan alluded to these with the problems of what happens is the person who goes to combat and the person who comes back from combat are not the same persons and we do not prepare the spouses and the kids for this and we've got to start doing this.
Speaker 2:This is another anticipatory guidance commercial. And because they are blindsided, daddy comes home and he can't even hold the kids because of what dan said, because every time he looks at his own child, he sees the children he killed. Now we've got it. We got to help these people, yeah, because we're going to need them again and we owe them, and we've got to start paying that debt. The same with police, the same with fire, the same with first responders, with teachers, all these public servant groups who are undervalued, our sanitation workers, our street cleaners, our water plant workers. We can't live without these people, at least not as we live now.
Speaker 2:We can survive, perhaps, but and we've got to recognize this we are basically living in our own little silos and we've got to get out of them and this is something I would be talking about in the, in the conference, for sure, and I look forward to talking with some of my psych colleagues, because we don't talk very much together and one of the things that the psych folk have got to do is get out of their offices and get out into the I'm sorry, the real world of their offices and get out into the I'm sorry the real world and train, as we have in public health community, people to do some of their work, make them, in the military terms, a force multiplier.
Speaker 2:No, they are not counselors and they can't prescribe and so on and so forth, but they can do crisis intervention, they can refer they, they can hold hands, they can cry with people, they can understand and support and they have time and and there are people who want to do this. We've done this in public health, with maternal child health for years and still do, and this is a, this is help for the, for the families, and we could do it for other groups if we, if we just took time to to do this um and it's and it's so important and and these people our military and those other groups I mentioned have done so much for us and they're. Most of what they do for us is invisible to most of us. So we, we don't even know.
Speaker 1:Yeah, I appreciate that and I think you know when you talk about the gap between what we know and what we do, coming to something like the Moral Injury Conference you get to learn about what other people are doing and how they're doing it, and then we can incorporate that work in our respective spaces. So, dan, you had asked for some final comments and I would love for you to take us home, yep.
Speaker 3:Okay. So, hey, thank you, I appreciate both Jamie and Sarah. Sarah, you're both real amazing people and I love the work that you're doing for Moral Injury Support Network, for Service Women Incorporated, and that you're doing for the larger. You know the larger world, because each of you have other things you do besides just work with missions. You have your Sarah. You're involved with Indiana University and Jamie does coaching and she does a lot of leader development stuff, and so I am super honored that both of you decided and chose and listened to the voice of God to join missions, be a part of what missions is doing helping people. It's my real pleasure to just say that I'm associated with you and that I get to learn from you and we get to work together to help, you know, make things better for lots and lots of people, for people that are thinking about. I would just say this about the conference If you don't come, it's you're really missing one of the most important events you could be at.
Speaker 3:If you're a psychologist, a social worker, public health practitioner, a veteran, a medical doctor, if you're a policeman or a firefighter, I mean we're going to talk about moral injury, not just about veterans. We're going to do a whole day on moral injury in women veterans. We're going to do a whole day on moral injury in families. To do a whole day on moral injury and families. We're going to do a whole day where chaplains and psychologists can get trained and certified in the Building Spiritual Strength Program. We're going to have exhibitors there that are going to be able to show their products and their books and their services and the things they're doing. So there's a lot of different ways to really learn from this and this could be, really, if you work in either a veteran support field, a medical support field, if you're concerned, you're a chaplain, public health practitioner, you know it's just almost endless really. If you're a nurse, you know nurses are often the first person to encounter someone and begin to understand they've got some deeper things going on than maybe the physical things that they're talking about.
Speaker 3:Then then the conference is for you and, uh, you should, you know, absolutely take the time, um, to attend and most for most of you, if you're part of an organization, your organization will pay for you to come because it's part of their. They all have training dollars for training because you need your continuing education hours and we're offering CEs for people. So, really, you know, I'm proud of the conference because of the people like Jamie and Sarah who said, hey, I'll be part of that and I'll contribute and I'll present something that I think can help people so super excited about the conference. Thank you so much, dr Archer, for being part of the podcast, for all you're doing for missions and others. Thank you, jamie, for, as a senior executive officer, helping me stay on point, helping advise the direction of missions. You know a lot of in providing your leadership, both to me personally and to the organization. I really appreciate it and thank you to everybody who's listening. Hope you share this with others because this is powerful stuff, as you know.
Speaker 2:Thank you. And thank you for your leadership, dan, that makes all of this possible.
Speaker 1:Absolutely. Thank leadership, dan, that makes all of this possible. Absolutely Thank you, dan. So we'll wrap it up. I just want to create a little bit of a sense of urgency. We have 50 in person at the retreat center that we'll be staying at and we'll have information in our subsequent social media advertising for this subsequent social media advertising. For this. There will be the opportunity for people to join us that stay in hotels offsite and they can come in every day, and we will also be offering this virtually for those who just can't make the trip to near Atlanta Georgia. So all that information will be provided in our advertising on our website and our Facebook page. So thank you again, everybody. It was an absolute pleasure, and that will just wrap it up.
