 Good afternoon. Can you hear me? Excellent. It's really exciting to be here. It's been kind of a focus of my career to sort of spread the gospel, if you will, of some of these ideas of morality and moral injury. And I especially appreciate being able to talk to folks that I don't typically talk to. So I'm in a clinical environment, in a clinical research environment, and I lecture to psychology interns, psychiatry residents, postdocs, psychologists, psychiatrists, researchers. That's really my world. And I'm always edified, and I learn a great deal by getting outside that world, especially my experiences in the last really at least 20 years of doing research and partnering with service members doing research and trying to enhance and improve the care of service members in theater and in garrison. So I welcome your comments. I would love to learn from you and what resonates with you about some of these things I'll be sharing, but also what doesn't fit. A good deal of the concepts around this idea of moral injury are controversial. It's somewhat like a Rorschach. Reactions depend on the person hearing these things. Chaplains respond a certain way. VA clinicians who are locked into a certain type of thinking about war trauma react a certain way, often negatively. Service members, leaders, I get a lot of different reactions. And I'm very welcoming of all responses. I'll share a little anecdote. I was presenting the behavioral health meeting of the Navy, primarily, and the Marine Corps in San Diego every year. It's like eight times the size of this room. It's an enormous setting with a lot of Marines and sailors and care providers in the entire Navy care community. And I was presenting on moral injury, and I thought, jeez, I know what I'm talking about, and I feel confident sharing it. And I still do. So after I got finished with my little thing, ideas which I'll share with you through these slides today, a Lieutenant Colonel on the Marine Corps stood up and shared that he resented in totality, full stop, what I was sharing and that his Marines could not be damaged by things that they were ordered to do, which are by definition moral and legal. And there was a hush. This guy was very powerful. And I responded, and we kind of had it out a little bit. I tried to defend myself. And I didn't want to not stand my ground. But it was kind of a scary moment. I'm not used to that sort of confrontation. Now, the interesting aftermath of that was, though, there was an article in the Stars and Stripes that said, Marine Corps rejects moral injury and it's like this contentious thing. And they quoted Lieutenant Colonel and me and created a stir about it as if there's a great divide. And the reality that no one would know is that I talked to this guy after my talk. And we came together and understood, you know, he better understood where I was coming from. A lot of people in the service is when talking to civilians. And I know I have some legitimacy because I treat veterans and have done my whole career. But still, there is a, let's face it, there is a disconnect and a lack of comfort often. But once he got through that and he understood that I was just, I just had a heartfelt desire to help, in this case, Marines and sailors. And I shared more of these ideas, which are hard to encapsulate when you give a talk. He started to appreciate it. And I got an understanding of where he was coming from. This is a long way of saying that. That is an incredibly valuable experience for me. It's a rare experience for people who are researchers and clinicians in that other side of the world, the VA, or the post-traumatic stress world. And that's really unfortunate. And so I want to share that a little bit. So I've got tons of slides and I won't get through all of them. I had a hard time selecting slides and content to share with you because I really wasn't clear on what you needed, to be honest. I'm not sure what you need from me, what would be useful for you to hear. So I'm going to share, basically this is a lecture that I give to trainees and psychologists and care providers in the VA and the DOD, so more therapists and people doing research and clinical trials and the like. This is what I tell them. So you're going to get a window into what I tell them about these ideas that they need to think about. Okay, so I'm going to share, now this is my vantage point and you have to understand where I'm coming from. But I'll share with you some of the lessons I've learned kind of getting out, again, outside the VA walls and appreciating the service culture and what I tell people in the VA culture about that and what they need to appreciate about the military culture and ethos because without that they're flying blind. I'll share with you why I started to study moral injury and why is that an important concept. I'll try to define the concept and speak to its prevalence and outcomes related to it and I'll share what we're trying to do to try to help service members repair moral injury and help them with their PTSD from it. Okay. So this is something you all know, I'm preaching to the choir, but really in the VA there's still kind of a, it's kind of a culture of still thinking about the military as if it was Vietnam. It's tacit, it's not in any way explicit, but there's this expectation that, you know, there's just dissatisfaction and people want to get out or that kind of stuff and I've had the, really the privilege of working again, as I said, with military leaders especially in the Navy and the Marine Corps, but also the Army and the things that I've learned I try to impart and so it's super important for clinicians in the VA side to appreciate how powerful the social culture is, the military called the ethos and how important leadership is and peer bonding and the like and how powerful in 99% of the case is a military career is and how, you know, one of the dynamics that touches upon moral injury that we deal with in the Marine Corps right now where we're doing a clinical trial and in the VA, people who got med boarded out, they're mad, they feel, they're resentful because they feel that they got betrayed and why? Because they wanted to keep their careers, they loved their work and their job. So, and there's good reason. There's, this is a time of, in our culture where the military gets tremendous support and appreciation by the about, you know, tremendous amount of resources, but so much attention is paid. I mean, look at how you're being trained and how that will affect people that you're leading. That's a tremendous thing. It doesn't happen, you know, in my work setting, there's, no one's getting trained to be a leader, seriously, but they're leaders and that's a problem. In the culture, it's important to note that, this was shared earlier, but I think it's important to underscore is that this is a different time. You know, there was, I'm a child of the Vietnam generation, grew up in the 60s and really at that time, service members were really seen with scorn. And unfortunately, and now it's different. The culture is very accepting of service members, honoring of them. So there's not a conflation of, let's say, beliefs about the validity of these wars and their cost and the outcome with support for the troops. So that's really an important thing. Okay. So one of the key things I try to impart, again, to people that need to hear this is that they need to understand that combat and operational experiences are complex and multi-dimensional. And in these incredibly long wars, which have taken such a toll on service members and families and communities and cultures, the just the stressors of deployments leaving the family behind takes a toll. Non-combat roles, service support roles or what have you are more at risk in a guerrilla war of uncertainty to be exposed to potentially traumatizing experiences or potentially morally compromising challenges? And traumas are so different in the military context than they are in the civilian world, yet PTSD as an idea, as a disorder, and its assessment and treatment are really focused on the civilian experience. And I'm trying to change that paradigm. Okay. So in our work, we try to make sense out of all the complexity of what might happen during war. And we've broken it down into three, what we call principal harms. A principal harm is the war zone event clinically or in a research context that a service member or a veteran says is the most haunting for them right now and the most currently distressing experience. So they may have had 20 things they could share, but what is the most currently haunting and most distressing event? We can categorize that broadly into three different types of experiences. Danger-based, loss-related, traumatic loss, and moral injury, which I'll describe. None of these should be elevated more than any other of them. Unfortunately, life threat danger is the sine qua non for PTSD. And at the core of our understanding of post-traumatic outcomes. And that's terribly deficient when it comes, especially to treating service members and veterans. Traumatic loss is a completely different phenomenology. It's the worst human experience. War zone loss, especially to someone close to you, is analogous to losing, like if I lost my child to violence, it's the worst human experience. And associated with the most horrific outcomes over the long haul sometimes. Added to all this soup is, again, what should not be ignored is just the general stress level and adversities of deploying, especially on the family. Okay. Another thing that I tell people is how important it is to appreciate the impact of combat and operational traumas and stressors or what have you, from a multidisciplinary standpoint, ideally an interdisciplinary standpoint. Interdisciplinary knowledge is egalitarian. Nobody's sitting at the head of the table. It's not a psychiatrist. It's not a psychologist. Everybody's got input and everybody understands the other's perspective. Unfortunately, psychologists have totally dominated the discourse about PTSD and have not reached out to others that know about the other types of impacts, biological, behavioral, social, relational, spiritual, and the effects on the family and the culture. So the impact of trauma is multidimensional and the study needs to be, and what's missing here really in terms of, let's say, the disciplines that need to get involved are you all. And there really is an unfortunate, there's a lot of VA clinicians that get trained and they never talk to senior NCO who's had a lot of deployments and a lot of responsibility and is very wise. And to get feedback about what they know and what they're doing. And that's a terribly unfortunate state of affairs. Okay. So as I was saying, the PTSD is dominated by psychological concepts. Basically, a traumatic event needs to be a life-threat experience, which in technical terms is like an unconditioned, it's like a shock in a, if you were thinking about conditioning. And the effects of that shock leads to conditioned reactions to reminders of the shock. And that's really, that's the fundamental core beginning of PTSD. That's where it came from as a fear-based disorder. It still resides in this idea that you need to have high fear to have PTSD. And I won't go into any more details that's quite clinical. The idea of a trauma as being a life-threat experience and affecting biology, there really are predictable downstream impacts of intense panic level fear on the body and the mind. And the study of that and the treatment of that has, there has been huge advances over the course of my career since 1987. It's really led to a revolution in the thinking about PTSD and caring for it, chiefly from a civilian standpoint. So therapies that are designed to target this high fear type thing and those downstream effects, the author was talking about how the sound of the horn and coming out and that's all fear-based. Unfortunately, the evidence for, although the evidence is incredibly, actually ridiculously great for existing evidence-based treatments for civilian-based, fear-based traumas, the evidence for helping service members and veterans with PTSD is very poor. So the question is why is that the case? And I have spent a lot of time thinking about that and trying to solve that problem. It's a fundamentally important question to answer and if we don't answer it we're doing a disservice to our service members and veterans. Okay, so my personal assumptions, again I share these with care providers and researchers but you should think about these things or know what we're thinking about I guess. I suspect as a culture and as a care community many outcomes, many of the dysfunctional outcomes or the psychopathological outcomes are going to be delayed. There's always a gap between or an important gap of risk that happens between active duty service and VA care or veteran status. Many don't use the VA. That's an understandable time of risk because you're losing your role and your sense of purpose and the good feelings that arise from being with your peers and the whole social life of that and feeling pride in what you're doing, what have you and you might have a job that you're unhappy about but I think a lot of outcomes will be delayed. I also assume and there's evidence to suggest this that and it's certainly the reason one of the reasons why we need to stop thinking about danger is the only thing that's going to harm service members that there's going to be great resilience. Resilience is defined as the ability to bounce back from stressors or traumas. There's going to be great resilience to danger-based experiences in the military during war. That is that most people if that was their focal prominent sort of thing that's haunting for them or distressing that's recoverable for a variety of reasons which I'll describe. By contrast traumatic loss as I was saying is really the worst human experience but added to that moral injury which I'll describe those are problems that have whose scars are run deep maybe hidden and because we don't think about those sources of harm we're not prepared to see it and address it and certainly loss and moral injury require a completely different thinking and that's kind of the focus of what I do. The experience of guilt from and and feeling culpable for the loss of a fellow service member is not something that you can just talk a lot about and be okay with it's not and but you can I mean this thing about talking a lot and being exposed to the narrative of what happened to you that doing that over and over again is there's it's there's unequivocal evidence that that helps with high fear experiences but if you just continually talk about how guilty you are and how sad you are that the brain doesn't work that way it doesn't it doesn't necessarily reduce you need another way of thinking about helping people and moral injury the shame from that the potential for self-handicapping which I'll talk feeling undeserving needs a different type of thinking. Okay the last thing I'll say from this slide which is important to appreciate and it's related to this idea of the the need to be multi at least multi-disciplinary and thinking about service members and veterans is that as psychologists you know they have these these great hammers or they think they're great hammers so that they see the nail and the nail is some kind of interest psychic something inside the brain and the thought process and the emotions shared of a service member or veteran that they need to talk about and make sense out of and get some feedback about but that's that's all it's needed and that's that is a terribly short-sighted and unidisciplinary emphasis focus on change and that it's impossible to help our nation's service members and veterans who are harmed by warzone stressors and traumas if we just attend to what's going on in their head real change requires doing things in in their world outside of a therapy session and I'll talk about some of those things okay so this came up earlier and I'd like to share some things about that this issue of why have we let's say the care community of the research community at least or maybe the service culture too why is it taking us so long to address these things that have that are universal and timeless there's a variety of reasons and and what I can say with some pride is that we're changing the culture and there's much more you know ease about moral injury in particular unlike last year the year before the year before there's still a lot of a lot of reluctance in the service culture and understandably so the the reluctance comes from like wait a minute you're saying that someone's going to have a mental disease because they did their job a legitimate perspective from my vantage point in our world like I was saying this fear this idea that you have to be frightened to have PTSD it has really blinded researchers and care providers I don't think we've asked the right questions we're starting to shame as this was discussed earlier today shame has prevented service members and shame and also inadequacy has prevented service members and veterans from sharing their experience so that the public could know care providers could know you all could know the more you know the you're you have a tremendous heart you're going to want to do something about it congress would want to do something about it but I don't think as a culture and in the society at large given that 1% serve there is great awareness I think that will change care providers may feel helpless or unprepared to deal with stories that are very hard to hear they're not sure how to respond so that that may have prevented some dialogue about that early in my career what we used to say is like well let's talk let's have this patient talk to the chaplain you know there's this real stark boundary that's a religious matter you know that's not going to cut it and the other problem is that we might be judgmental about these things moral transgressions we're all we all are judgmental about others behaviors but we can't help service members and veterans unless we come from a place of compassion and forgiveness really and that's what we need to promote okay so I've tried to in a couple different ways to define this idea of moral injury this was the first attempt which didn't make the cut but it's worth talking about because this is my original idea when I thought about moral injury I was thinking about my clinical experience with Vietnam veterans which is really how I started my career and as a as a person in the culture the the idea of some a small but salient percentage of Vietnam veterans going off the grid and disengaging from society and filling the jails and what have you and anticipating the possibility of the of long wars and of unclear outcomes I thought that that moral injury could be this sort of a broken moral compass that is that you you did things or saw things that that kind of broke your understanding of how things work and your expectation that people will do the right thing or you can you you do the right thing that you have goodness in your heart you know and once that's broken you might disengage from moral expectations so that was the original idea there's still some validity to that and I think that the delayed outcomes of these wars I I've talked about before I think that we don't know yet whether there will also be kind of a post 9 11 wars section of society veterans that go off the grid or or start to fill the jails something we need to watch out for this is the working definition that we've published that we've that the VA is is comfortable disseminating it's worth just saying out loud so moral injury is the lasting psychological biological spiritual behavioral and social impact of perpetrating failing to prevent or bearing witness to acts that transgress deeply held beliefs moral beliefs and expectations fairly broad but it's a good starting place the key here is transgression and in order for a transgression it's events aren't transgressive it's reaction to those events so I'd like to say that that war zone events are potentially morally injurious but they're not inherently morally injurious you need to have the perceived transgression so we've done I'll share some research we've done on the aftermath of killing in the war zone in the VA and that research has has been distorted somewhat because people who are not in the know take it as well killing is harmful and that's not the case killing as was discussed earlier it's it depends on the context perhaps it depends on the proximity and and your ability to discern the humanity of who you're killing and I thought that was a great point earlier but events aren't inherently damaging let's see if this works okay so taking a step back just to kind of emphasize the distinction between danger life threat and moral injury if you're interested this slide just sort of shows you that there are different things that happen behaviorally and psychologically and there are different needs that arise from loss there's certainly if you think about it there's a completely different need that arises if you're really scared and you can't calm down and you don't want to go out again then if you lost someone that you love and that you you depended on for your well-being and they depended on you for their well-being it's a different need on a human level there's a different need that arises in the short term in the long term yet the field is focused on life threat there's a different need that arises from feeling that you have transgressed a need to be punished okay so what what have we found in our research that is potentially morally injurious that's important because again it's potential not inherent there's nothing inherent about events well there's prescribed ROE killing we've done some research on that that can be potentially morally injurious collateral damage to human beings bearing witness to intense human suffering there's no one that has that has articulated the damage that could happen from bearing witness to carnage and the aftermath of violence then Romeo Dallier who was the head of the peacekeeping operation in Rwanda and General Dallier and he wrote a book tremendous person and he wrote a book about his experiences and I wish I had a quote here but it was peacekeeping wasn't his job wasn't to harm an enemy you're not supposed to take sides that was mentioned earlier and his reaction on a human level and and as he's described as he describes it in this book you could understand how powerfully harming that is especially for a service person who wants to help can help but isn't unable to so helplessness can be a theme to that the sort of bearing witness to grave human suffering and then there's the potential for proscribed violence acting out behaving brutally and then betrayal which is something I get asked a lot about but from VA clinicians because they they they feel like they can't help their patients because they're just mad and and they don't feel like it's their job to help help themselves it's like they got screwed so betrayal by leaders if a leader made a capricious decision I resonated with what the general said this morning is powerful you have so much responsibility but I'm I'm I will tell you that perhaps it's unavoidable but but there are people that you're going to be in charge of that will feel betrayed and and a lot of it comes with needing to leave the service but this it's powerfully scarring and it can be all consuming to feel like very resentful and angry and to be what is known as externalizing like you feel like I didn't do this so why should I be in therapy or whatever it's like you know I'm the victim that's a that's a very hard problem to tackle I wish there was a way that you all could help service members before they leave the service feeling resentful and angry I doubt that there could ever be a conversation really given how the some some service members feel when they're leaving okay well I skipped something all right I won't go over the details of this we've done a series of studies looking at the aftermath of killing so some of these are based on just getting almost like focus groups together of Iraq and Afghanistan veterans and Vietnam veterans together and getting them to talk about you know what killing experiences what it was like their their aftermath and what have you and what we've shown is that there's the potential for harm by from these experiences and that's a conflict because it's an occupational hazard someone asked about prevention earlier I think it was over here that's a great question I would not lose that question I think prevention is possible I think part of the reason why loss and moral injury is more toxic is that there aren't rituals there aren't conversations but in the military there's great training and preparation very hard and realistic preparation for warrior roles and doing hairy stuff is consistent with the warrior culture and ethos so you can be almost proud about it or maybe really proud about it and excited about it and you can share those stories but try sharing stories of feeling like you let somebody down or actual culpability for loss anyway so so killing is one of those things that can be damaged you know all sorts of ways creates greater risk for suicide suicidal ideation depression PTSD substance abuse for those of you who may want to know we we so part of the scientific study of these things you got to first define it define a construct define an idea you know that everybody can agree on that makes sense and then you got to find ways of measuring it so we we developed and published a measure of morally injurious experiences that we use in our research if anybody is interested you can email me this is an interesting I'm I was heartened that earlier there was a conversation about this so there's something called a petted aggression and it's this real phenomenon of human beings having very old brains in addition to a more evolved part of your brain but we're very much driven by our old brains and in our old brains hunting and killing was is we're hardwired at some level often very explicitly and automatically it's not your choice per se there's a pleasurable aspect of that so being predatory and goal directed in a high threat environment where you have mastery and control that's powerful and it's reinforcing and it feels good it hasn't been discussed it's kind of a one of these things it's kind of hard to talk about but there there's even you hear off you know some reports of sexual pleasure from killing again hardwired it's not a choice and so the prediction that I have is that that's probably the most hard the hardest thing to accommodate which is to accept as part of who you are you know how do you how do you regain your humanity after feeling that you know and that's something that we have to tackle and be realistic about interesting study this last thing there's like one study of this phenomenon and it was with nazis actually who had you know who were evaluated for PTSD you know many many years after World War II and those who reported a lot of repetitive aggression that is excitement and good feeling if not arousal we're less likely to get PTSD so food for thought okay so are there morally injurious experiences in war that's one of those duh things of course there no one I don't think anyone would dispute that that there are potentially morally injurious experiences and and what we underscore in our work is that service members are uniquely at risk for moral injury in part because they're trained to be so highly moral and ethical unlike any organization I've ever been exposed to it's built in and hardwired and so when there is the experience of transgression it's even it's even you hit you're hit even harder this was a mental health advisory report which is a team of in this case it was army personnel from Walter Reed at the time who went in theater and asked soldiers and marines you know what they were up to and and these were the some of the things that were reported and this makes me feel a great deal of pride that you know I live in a country that the military was not did not intend to be blind to these things so so the leadership had to see these things and wanted to see it otherwise it wouldn't have been evaluated and these these are the things that were reported in this mental health advisory team for example 45 of these service members felt that non-combatants should be treated with dignity and respect 31 indicated that they had insulted civilians now again potentially morally injurious okay other signs of prevalence we I'm part of this consortium that the do d funded to do clinical trials of psychotherapies for PTSD in the in garrison so these this work happens at Fort Hood and so what we do is we we we determined the principal harm most currently haunting and distressing experience and then then we categorize it and it's categorizable and these are the events that have led to PTSD so so if you if one of your question is whether a morally injurious experience can lead to PTSD the answer is 100% yes as is the case with laws and this was the breakdown it's a little more complicated than it needs to be the last three are these the the morally injurious but the potentially morally injurious experience actually these are these were morally injurious by definition because they are they were traumatizing it's a pretty high percent for these soldiers and these are treatment seeking soldiers in garrison at Fort Hood in another study we piloted a therapy that if there's time I'll share with you to try to target loss of moral injury with Marines at Camp Pendleton and this was the breakdown of events reported in in these treatment seeking Marines life threat less now Marines are perhaps unique in the sense that they may be less likely to endorse a danger based experiences experience so is there a syndrome this is so when I get interviewed by the media this is the question they want to answer they basically want to look for a mental disorder and you know they want they want me to say moral injury is this and it's in the DSM and it's a psychiatric condition and it was never my intention and for this work to develop another disorder we've already overly medicalized post-traumatic adjustment in my opinion too too quick to identify mental illness PTSD is a mental illness and that term is not used because it's kind of unattractive but it is a mental illness like schizophrenia it's a formal mental illness I did not want to generate another formal mental illness but there are some predictable things that we have seen and that we we've predicted or that we would predict one is fundamental to PTSD is this really is this idea being haunted by a life event the whole thing if you just look at it the right way it's about what happens to the body mind and spirit if you're haunted and so with a morally injurious experience you're going to be haunted by it and that's manifested in these re-experiencing symptoms you hear about in the PTSD so there's overlap of PTSD and whatever syndrome might occur in terms of moral injury in addition to PTSD let's say and there's shame and guilt um guilt as a symptom was was in the original DSM3 definition of PTSD which was which was born from Vietnam veterans rap groups and such and it didn't make the cut in DSM4 and and so and in five it's it's conceptualized only as a victim in a victim kind of frame like guilt that you don't deserve and it's irrational guilt and that's unfortunate there's a lot of guilt and which comes from culpability that we can't deny as care providers that there's real experience culpability for that and then the VA community is is basically a hundred percent prepared to see a transgression as not entailing real culpability and and that's a problem I think that in many ways we have to start with the reality of the service member and often culpability is in that context and when you feel culpable a loss is not a loss it is a profound guilt inducing experience um and then the shame shame is about self-loathing moral injury it's ready you know easy for anyone to think about moral injury as a shame inducing kind of experience um and then there's some downstream behavioral effects that you may not see in the service culture you might see in the VA more which is not caring whether you have a successful life self-care kind of goes out the window or um actual self-harm driving too fast poor self-care uh and and then and then frank self-handicapping like getting intoxicated uh the day after I have a job interview or something like that stemming from this idea that you're not deserving and so that often leads clinically to a maybe a couple steps forward and many steps back and then there's the spirituality deficits there there may be anger at God lost faith it's kind of about this idea of theodicy why would God let that bad stuff happen and the potential for anger and aggressive behaviors okay so the challenge is I won't talk about prevention that's another conversation but how do you repair moral injury and in in our work there really is a danger for VA clinicians to to see behaviors as either contextual that is this was you then doesn't speak to you as a total person you gotta you gotta speak you gotta have to understand who you are now i'm moving forward in the words it just sort of something that happened then you're not really culpable if you think that you if you feel bad about yourself there's some distorted thinking there there's either that kind of thinking and there's a tacit expectation that if people do really harming things and let's say really bad acting out things really bad acts of transgression in the war war zone that that's like psychopathy but like you're acting like a psychopath which is that you don't have a moral you don't have goodness you don't really care that's a real problem but that's that's there's kind of an undercurrent of that and that counter to that way of thinking in our model if you are in pain and you're seeking help by definition you have goodness and there is hope regardless of the transgression um and that it is possible for you to reclaim that goodness and just to find some peace and some forgiveness that's fundamental um and in that model we we we cannot be judgmental we cannot be judgmental another assumption is that goodness is reclaimable because if you're in pain about something you did or failed to do let's say you're in pain because it's what you did is is counter to your value system and that value system has a core morality and a core core personal goodness um so there are two roots to moral repair healing recovering one is sharing disclosing meaning making and the other which is much more challenging but much more important is just doing repairing things in your life in your world um connecting with others giving back and the like how much time do i have five minutes okay so i'll just end here um and just share the the outlines of a psychotherapy we developed called adaptive disclosure uh we have a book coming out it's on this slide gilford publications and this is a book where we we kind of uh which we basically tried to change the paradigm of psychotherapy at least for service members and veterans and we developed this therapy that that in one therapy we individualized the care uh based on the principal harm if it's fear-based danger-based then we know what to do there's you know a real existing technology for that if it's lost we do some different types of procedures um and then if it's moral injury we do even different things so we acknowledge loss and moral injury we treat it differently um we piloted this uh therapy and we have a current clinical trial in the marine core um the thing i'll end by saying is that what's drastically different in this approach is one of the things that led me to actually to think of these new strategies was the fact that the reality is that most care providers are young they're not sufficiently trained about the military culture and ethos and um they aren't um easy to talk to you know certainly inherently and um they can get there um so we we took some of the therapy elements basically out of the hands of the psychotherapists or at least out of their mouths and what we did was in adaptive disclosure we have service members and ultimately veterans have an imaginal conversation if it's a loss we have the they have an imagine with their eyes closed they have a real-time conversation with the lost friend and the idea is to confess and share all the deep dark and awful things that happen that led up to it that um and one one's own reports of personal responsibility if they exist and also confess to the friend how how you have been doing what this event means to you and how you have are going to go about your life now and usually what gets told is how you you should not be happy you shouldn't be successful and you need to suffer and then the eventually there's a uh a similar conversation if you will with this lost person through the voice of the patient about what their reaction is what do they want from you um if it was reversed what would you want from them if it's moral injury we have a the dialogue occurs with a forgiving compassionate and moral authority and that's also entails a stark poignant evocative confession but it doesn't end there it's also a conversation about what you have done since this event and how it's affected your life and what it means to you and you get feedback from this compassionate moral authority if you can think of somebody who's been compassionate and forgiving in your life that means that you have a core of goodness they saw that in you and what it means is that they will can um provide you feedback through your own voice because you'll know what they're going to say um about well that was awful and that's unacceptable and they're going to be you know aghast about certain events but they're still and they still have your back they still think that you can repair this that you're going to have to give back you know volunteer your time whatever um and find goodness again so and we just do this to start a process because ultimate change is in in the world of that service members and veterans live in so i'll end there and take questions i hope