 Our next speaker this morning is Naranjan Karnik. Naranjan is an associate professor of psychiatry and nursing and the medical director of the road home program, a program for veterans and their families run at Rush University Medical Center. And Naranjan is also a staff psychiatrist at Heartland Alliance for Human Needs and Human Rights and is a faculty member at the McLean Center. Naranjan earned his MD and his PhD in sociology at the University of Illinois. He completed his residency as well as his fellowship training in child and adolescent psychiatry at Stanford. Today, Naranjan Karnik will speak to us on the topic treating moral injuries of veterans and their families. Please join me in welcoming Naranjan Karnik. So Mark, thank you for the invitation to speak. Before I start my talk, I feel that I need to make note of yesterday's events in Paris, not only because of the tragedy that this represents for the city of light, which I know will recover from this, but I'm cognizant of the fact that the veterans that I work with and people like the veterans and families that I work with are often the ones who are called upon to respond to these types of events. And they do so willingly. They do so with a great deal of bravery. And it is one of the great privileges of my career to actually do this work. And it's an unusual path for a child psychiatrist to be in. So I just want to make note of that before I begin. These disclosures, none of these actually are material disclosures, I believe, that represent conflicts of interest. I am an unpaid research physician to drug studies that are going on at Rush for no other reason and they needed somebody to be there as a backup. And I serve on the board of directors of a not-for-profit corporation. Again, I will not be discussing anything in relation to these. The list of funders that you see here are the major list of funders that fund the Road Home Program. And the Road Home Program exists outside of the VA system. We benefit from close collaborations with our local VAs, but we're able to provide care to veterans and their families without any regard to their ability to pay, largely because of these funding agencies. These are the current estimates of the U.S. armed forces. They're about 1.4 million as of August of this year who are active in the armed forces and that includes all branches of the armed forces in including the Coast Guard. The current veteran population as of 2014 is estimated to be about 22 million veterans. And just for reference sake, the U.S. population as of that same year was estimated to be about 319 million. What you see among the veteran population among active military is increasingly female population. People may not be aware that in the post-911 era, almost 20% of the active duty military who were in that theater were female. Increasingly, there's a minority population. The military recruits significant numbers of African-American, Latino populations into the military. And so you see that shift. And about 25% of current veterans in the U.S. served during the Gulf War era. So this is post-911. And that has some significance for those of us who work in this area. So I feel before I go on, I need to address this question. How does somebody like me end up running a veteran center? So as a medical student at the University of Illinois in Urbana and then a resident at Stanford, I trained at VA hospitals. Some very good VA hospitals in fact. And I actually think it was one of the most important parts of my training as a physician. The veterans are a wonderful population to work with and I learned that very early on. In 2011, as a University of Chicago faculty member at the time, I was actually approached by a fourth year medical student to advisor on a research elective on military sexual trauma. Now, this was before military sexual trauma had any sort of public attention to it really. And this student asked me to supervisor and I said, look, I've seen a couple cases while I was at the VA, but you know, I'm not really an expert in this area, but I think I know a thing or two about trauma. So if you're willing that I will learn along with you, we will go down this road together. She and I actually worked rather closely and subsequently published a review paper in a family medicine journal because that was her projected career path. This has the aliens that I didn't know would be later on. In 2013, I moved from University of Chicago to Rush. And in March of the following year, I was tapped to oversee the children and families program within our veterans program. So this is really what distinguishes this program from what the VA can do. The VA by statute can't really provide the type of family based care that we do. And so I was asked to run the children families program and shortly thereafter, they sort of sprung this on me and asked me to run the whole program. I went on vacation at the end of June for two weeks and I came back in July and the chairman of the department surprised me and said, I need you to write a grant. The grant is for $15 million and you have two weeks to write it. So we wrote it and it subsequently got funded. So that's how I end up where I am. So what are moral injuries? So there's a substantial amount of writing in this area and I think my colleagues here who work in the VA system will be familiar with much of this. The index point in some ways of a great deal of conversation was Jonathan Shea's really excellent book called Achilles in Vietnam. And in that book, Dr. Shea describes basically three elements that he thinks are essential to understanding moral injuries. One, there's a betrayal of what is morally correct and I'll talk about some examples of this. The second part is there's action by someone who holds legitimate authority. And third, that this takes place within a high-stakes situation. It is generally accepted within the subfield of people who work on moral injuries and post-traumatic stress that these two experiences of moral injury and post-traumatic stress are not equivalent. They may be highly comorbid, but one is different from the other. And increasingly we're starting to have discussions that moral injuries likely require a different set of tools to address. And I'll get to some of that towards the end of my presentation. So here are some examples of what I have been told by veterans in the clinic. I went over there to protect my family and friends and now I wonder what it was all for. I lost buddies over there. I saw them die for their country and it turns out that our politicians lied to us about everything. And here this veteran was referring specifically to the findings of weapons of mass destruction and Baghdad and the controversies that emerged over how that information was discovered or not. I was asked one day very plainly, why did we do it? So as a psychiatrist who tries to stay back from these specific questions, these are very hard questions and in some ways they demand an answer. And another veteran said that betrayal is even worse when it comes from within your own group and your own leaders. Very much reflecting back to Dr. Shae's definition of that legitimate authority that's been used incorrectly. I haven't come up with good answers. Every time this has happened, I've now come to anticipate that it will happen. I haven't come up with good answer. The only answer I have been able to marshal up in response to these questions that I'm asked is that history may judge these events differently. And we have a discussion about that and I think our own personal political philosophies need not cloud the fact that in essence these individuals need care. So one of the things with moral injuries is like throwing a pebble into a pond, it reverberates. The injury actually goes beyond the individual and one of the things that we find at the Road Home Program is that it impacts everyone. It impacts the family. In fact, spouses and significant others. So the waves from this continue. And one of the things that has come up in the context of this is moral injury has classically been defined as something akin to doing acts in a time of war that run counter to their personal ethics. For example, killing enemy combatants. So I hear from veterans who have been in situations where they've had to kill combatants. At the time, they were told that they needed to do this. They were trained to do this and they come home and they reflect upon this and it's hard to reconcile their personal beliefs which generally run counter to this. They don't wanna hurt people. But yet that was their job and they were asked to do it at the time. And from this comes that Genesis point of moral injuries. And if you read through the moral injury literature you'll see many such examples. Interrogating individuals. Most people in here are probably aware enough or tied to the media enough that they know about many of the events that have happened about torture and victimization of enemy combatants that were held. And we've had individuals come into our center who have talked about this and having to be part of this or having to even be witness to it, being bystanders to it. That secondary impact of feeling like they can't act. But I wanna add to this a question that I ask myself and ask all of you and that I debate with my team that is military sexual trauma type of moral injury? Now I'll get into what military sexual trauma is but I will just point out that this is something that impacts the individual as an attack from within their unit. Trust being essential to military units to function. They all have different duties, different roles. They have to rely upon one another. This type of event goes to the heart of that. It has been likened in some of the writing on military sexual trauma to a type of incest injury because the military is such a close family system in some ways until recently people would talk about it as a brotherhood. Now it is a kinship that includes both genders and that if you view it in that family sense it is a type of incest injury. And it's part of a class of injuries that cannot occur outside of our zones. So in that sense moral injuries share this uniqueness that they take place there. Rape and sexual violence can certainly happen but this type of intra-unit or intrafamilial injury is somewhat unique in its nature when it happens within a war theater. So I would push and say that moral injuries are those injuries that emerge in the context of war actions that cannot easily be reconciled with civilian activities. So this is the definition of military sexual trauma that's in essence used by the Department of Defense. It's a physical assault of a sexual nature, battery of a sexual nature or sexual harassment which occurs while the veteran was serving on active duty or active duty for training. And it's characterized by some of these events. So these are some of the prevalence and projections and I think these should be very sobering to us. These are studies that come out of the VA. This is Nicole Ballrush's and I have the reference at the bottom here is the paper that we published where we synthesized all the available data at the time. There's some more current data that's come out of the RAND Corporation since then. But roughly one in five women serving in the military have had some instance of military sexual trauma in about 1% of the men. And you see that the numbers of survivors then total up to about 400,000 women and 200,000 men. Now when I took over leadership of the center I didn't anticipate that military sexual trauma would reemerge after this paper that I'd written so long ago even though it was published in 2013 the work was done in 2011. I didn't think it would reemerge. And what ended up happening is that people started showing up at our door. These show the first screen here on your left shows the frequency of females reporting military sexual trauma at our clinic. This is about the first 150 or so who come in we're at about 275 now veterans who've come to care. So about 70% of the women who come to our clinic report military sexual trauma and about 10% of the men. The men were somewhat the surprising number in this and unexpected to our team. And it turns out that a significant fraction of those men actually were from the Vietnam era who were coming to our clinic and hadn't discussed this. Actually didn't even have a term for it until the reporting had happened on sort of women and military sexual trauma occurring in recent years. And they were finally able to reconcile that with their experience that happened there. So they come to us and the VA has many good clinics and treatments for military sexual trauma. The attention in the VA system has come to this area. But what the veterans who come to the Road Home program tell us is that the reason that they come to us is that going to the VA hospital can be very activating for them. Being around a quasi military environment, seeing people in uniform at times can be very triggering and they prefer to come to our clinic because our clinic looks like a rather nondescript outpatient clinic and doesn't really match with that. This leads me to one other point in that my role in this was somewhat unusual. So the reason why I came to this, when I joined the Road Home program, it had already started to take shape. It was emotional already and it already discussed with the director of the Women's Mental Health Clinic at Rush that she would lead the military sexual trauma program. Shortly after I took over as medical director, my colleague went on maternity leave and I was the only other psychiatrist available. So the therapists who were working with these individuals in the transition plan said, look, Dr. Remnick's in a leave, are you okay seeing a male provider? And for the female victims and the male victims of military sexual trauma, it can be very difficult to talk to male providers. So they started this discussion with them and especially the women, there were a few for whom they preferred not to see a man. So then my team, being ever the industrious team, decided to tell these women, well, he's a good psychiatrist and he happens to be gay. Would does that make a difference? And it turned out that it made a difference. And so then they decided that they could come see me and despite my colleague's return, a few of them have actually stayed in my practice and I continue to follow them. I gave them, I said, you know, Dr. Remnick's back, you can go see her. No, no, we'll continue with you, it's fine. So on almost every score, the victims of military sexual trauma versus individuals who present to our clinic more generally have higher rates of everything. So you will see higher rates of PTSD. This is on the PCL-5, which is a measure we use to assess PTSD. You see on depression, they're worse, anxiety, they're worse, it's almost the same graph it actually isn't. Now as a shout out to my colleagues here who trained with me here in the McLean Center Program who were in the NICU and did a lot of work on them, I pull this in because I think it's an interesting study out of the VA, looking at 16,000 deliveries at the Veterans Health Administration. And they studied active PTSD, so symptoms within the last year, historical PTSD, which is symptoms greater than a year, and no PTSD. They found that the odds of spontaneous preterm delivery were greater in active PTSD and even higher in MST with PTSD. And this is their data. And you see that the odds ratio for that first line, which is the active PTSD and military sexual trauma actually has the most impact. It's actually the only significant one on there. So this experience has repercussions. And as I said earlier, like pebbles in the pond, the reverberations go out and it impacts families. So here you see this kind of ongoing drama that is what we see. That the individuals with military sexual trauma have higher stress severity. They have a perception of their family functioning as being worse. They perceive their social support as being lower. They perceive their social support from significant others as being lower. They perceive their social support from family members as being lower. And social support from friends as being lower. Mark, I'm going through this as fast as I can, all right? Couple satisfaction in individuals with military sexual trauma are lower. And alcohol use is significantly higher, especially among the male veterans who suffer from military sexual trauma. It's almost double what it would be in the individuals without military sexual trauma. So what do you do to treat moral injuries? What are we doing? So one of the things that we are in the process of doing right now is that we are assembling a moral injury treatment team. So who would be on this team? Well, we have psychologists who have particular experience and expertise in this area. We have LCSWs who are interested in this and working very hard on this. We are, for the first time, bringing a chaplain on board, which is somewhat unprecedented for our type of program to have that. Chaplains are very much a part of the VA hospital system. But in terms of a private university, hiring a chaplain specifically for one outpatient program, this stands somewhat alone at this point, as far as I know. We are continuing to treat military sexual trauma with PTSD methods. So the evidence-based methods that we use are drawn from the PTSD literature. We do so without knowing whether this is actually the right choice. Prolonged exposure is one technique that is used to treat PTSD. And we are using that in our clinic. We use cognitive processing therapy as well. There are others, a handful of others, such as EMDR that are used. But we haven't yet deployed those. The most interesting thing I think we are doing is doing this. We are using a model from UCLA called Families Overcoming Under Stress, Focus. Focus uses a family-based approach to treat military stress and trauma. And it doesn't get into the details of the trauma in great extent. It uses a system of family-based narratives where every individual in the family gets to tell their story. And then those stories are brought together. So the parents or the significant others talk, and then the children get to tell their stories. And here we use family actually according to what the individual veteran defines as their family. So we would take adult caregivers as family. We would take partners, significant others. We had one group of veterans come to us out of the Day Hospital at the Jesse Brown VA here in Chicago who came to our clinic together. The three of them had sort of formed a very close relationship during their time together in the Day Hospital. And they decided that they were a family. And we decided to treat them as such. And the flexibility that we have in doing this. Focus allows us to take their individual stories and weave those together. And to look at ways in which they had strength and resiliency in the face of stressors in their lives and build from that. And it actually has a strong evidence base. Our colleagues at UCLA have used this with the Navy SEALs. It has now become one of the major accepted modalities for the special forces within the military. And they are generalizing it across their entire system. So this is one thing that we are now working with UCLA to hone this technique for use with military sexual trauma. And they're working with us in a very collaborative way. It's a wonderful thing that we get to do. Finally, we're pursuing research on military sexual trauma and on moral injury. We have several active studies that are going on that are in progress. The MST research is largely being done by our team. We are joining ongoing studies at Duke and Urbana-Champaign that are looking at measurement of moral injury and trying to capture moral injury. So I want to thank my research team. All those graphs that I showed with the data, Randy Boley, who's my research coordinator, really put those together. Our MST team is a very gifted team. And now we have another psychiatrist on that team. I will make and see some of the patients. And I have a very good administrative team that works with me. So feel free to stay in touch if you have questions about this. Thank you. Yes, Robert, we'll do one question, please. So Dr. Karnak, as you know, I do counseling with combat veterans with PTSD, a lot of prolonged exposure in cognitive processing therapy. What I'm curious about is second wave therapies rooted in cognitive behavioral therapy look at challenging cognitions, automatic thoughts, intermediate beliefs, but not core beliefs or core values. And in third wave psychotherapy, like acceptance and commitment therapy, which Sharon Maduin who studied under LITS is looking at with moral injury, those look at cognitive diffusion of thoughts separating you from these ideas. What I'm curious about in my work with this is what's the moral authority for changing such a deeply held value of it's always wrong to kill a kid? It's a great question, Robert. My job offer to you still stands if you wanna come join my team. More than happy to bring you on board. I'm gonna go blush. Yes. I tried to recruit him a year ago, I will continue. But I think in some ways, I think the acceptance and commitment therapy is gonna be one of the ways that we will start to move. We are actually starting to do some research around that and also around self compassion. Not as a way of trying to undo those beliefs, right? But as a way to reintegrate them into their self in some ways. And these are really, we've stuck to the evidence based modalities for now and we will sort of basically trial these other second, third generation treatments against those as we move forward. And I'm hoping that we will find something better. Yeah. Norendra, thank you. Great, thanks. Thanks so much.