Statewide Symposium in Support of Service Members, Veterans & Their Families Clinical Knowledge & Skills Track & General Session Please note that topics, schedule and presenters are subject to change. The updated agenda is posted at: www.ArizonaCoalition.org/symposium DAY 1 – April 22, 2015 Title: Introduction to Moral Injury and Moral Repair (breakout session: 1045 – 1215) Presenter: William Nash, MD Description: The history and development of the concepts of moral injury and moral repair will be reviewed, including a survey of the empirical studies and theoretical papers that have contributed to these emerging constructs. The range of potentially morally injurious events will be reviewed using two existing validated psychometric measures, and illustrated with a video clip of an interview with a wounded warrior. The probable mechanisms of injury in moral injury will be compared with those believed to mediate the symptoms of posttraumatic stress and loss injuries, and symptoms will be compared across these three types of stress injuries. Emerging approaches to moral repair will be introduced and discussed from biological, psychological, social, and spiritual perspectives. Learning Objectives:  Define moral injury in terms of both the stressor events which cause it and the symptoms and behaviors that commonly result from it  Articulate the ways in which moral injury is similar to PTSD, as well as he ways in which it is different from PTSD  Name the two existing self‐report measures currently available for the assessment of exposure to morally injurious events Title: Polytrauma and Moral Injury: A Multidisciplinary Team Conversation (breakout session – 1315 – 1445) Presenters: Mary Lu Bushnell, Alex Hishaw, MD, Doug Little, MD, Adam McCray, PhD, Blake Chaffee, PhD, William Nash, MD, CH (MAJ) Bradley Walgren Description: A panel representing different roles from a multidisciplinary clinical team (e.g. military psychiatrist, VA neurologist, VA neuropsychologist, military surgeon, Vet Center psychologist, VA social worker, VA polytrauma director, military chaplain, and researcher on moral injury) will describe the use of a “moral injury lens” as a conceptual tool in assessing and planning interventions for Service Members and Veterans with polytrauma. Neurobiological concepts, the complexity of moral injury, and its potential impact upon the client’s ability to engage effectively in treatment for mental health conditions will be discussed. The presenters will examine the issues of loss, betrayal of trust, burden of shame and guilt, and other emotional and behavioral signs and symptoms of moral injury. Strategies and interventions that relate to a “moral injury lens” conceptualization strategy will also be explored. Learning Objectives:  Demonstrate an awareness of the implications of using moral injury as a lens for assessment and intervention in combat veterans. 1 
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Define and contrast the neurobiology and symptomatology of moral injury versus PTSD and discuss differing approaches appropriate to each condition. Describe the value of a multidisciplinary approach to assessment and interventions concerning moral injury. Articulate potential impacts of the client’s moral injury on family participation in the recovery process. Title: Moral Reasoning (breakout session: 1500 – 1630) Presenter: David Jacobson, LCSW Description: The goal is for those present to be able to gain an understanding of several strategies or methods that can be utilized in relation to moral/ethical decision‐making. Also to introduce the CASES model that the Veteran Health Administration utilizes to assist with ethical decision making nationally. Learning Objectives:  Recognize that ethics and moral decision making is not intuitive, absolute, or easy, but instead requires constant practice.  Identify various ethical perspectives, and demonstrate how they apply in a variety of settings.  Indicate the importance of developing/acting on alternatives as a critical component of ethics. DAY 2 – April 23, 2015 Title: The Neurobiology of Extreme Stress, Broken Down Barney‐Style (general session: 0900 ‐ 1000) Presenter: William Nash, MD Description: The many advantages of a neurobiological approach to studying, preventing, and treating extreme stress from all causes will be reviewed, including its unique power to explain otherwise inexplicable variations and comorbidities of stress injuries, and to dispel toxic mental health stigma. Using simple visual aids and a minimum of neurobiological terms, a method will be demonstrated for the psychoeducation of service members, veterans, and their families in the role of the brain and central nervous system in stress of any kind, and in the production of the cardinal symptoms arising from stress that is too intense or lasts too long. Probable changes in structure and functioning in four levels of neural organization (autonomic nervous system, nucleus accumbens, amygdala, and prefrontal cortex and hippocampus working in concert) will be described for four classes of extreme stressors (life‐threat, loss, moral injury, and cumulative stress). Key concepts for restoring brain health will be introduced. Learning Objectives:  Recite at least three reasons a neurobiological understanding of extreme stress may be indispensable for the treatment of stress‐related health problems in military service members, veterans, and their families  Explain common symptoms of extreme stress, including PTSD, with alterations in structure and functioning across three levels of organization in the central nervous system: the autonomic nervous system, subcortical emotional brain centers, and the prefrontal cortex and hippocampus 2 
Recite specific techniques individuals can use to promote healing, regrowth, and integration of their own stress‐affected brain systems Title: Current Challenges in the Treatment of Moral Injuries (breakout session: 1030 – 1200) Presenter: William Nash, MD Description: After reviewing several dimensions of moral injury that have attracted attention as targets for its treatment, a model of moral repair based on the reconstruction of damaged moral identities will be introduced. Key concepts to be discussed include the differences between moral reassurance and moral repair, the importance of constructive action in the recreation of moral identities, and the important role of significant others in the co‐creation of moral identities. Two specific psychological treatments that are currently being evaluated as adjuncts for moral repair will be discussed in terms of these key concepts: Adaptive Disclosure (AD) and ACT (Acceptance and Commitment Therapy). Audience participation and discussion will be encouraged. Learning Objectives:  Define moral repair in terms of reconstruction of moral identity  Explain the difference between moral reassurance and moral repair  Compare the roles in moral repair of health care professionals, family members, religious ministers, and community leaders Title: Military Cultural Competence in Practice: A Multidisciplinary Discussion (breakout session: 1300 – 1415) Panelists: Dianne Lethaby, William Nash, MD, Adam McCray, PhD, Thomas Winkel, Kristin Musch, RN, Chrystal Snyder Description: A panel representing different roles from a multidisciplinary clinical team (e.g. VA social worker, VA nurse case manager, Vet Center psychologist, VA polytrauma center director , and military psychiatrist) address the implications of military culture for assessment and intervention planning for military and veteran clients with co‐occurring physical, psychological, and/or neurological health issues such as traumatic brain injury, post traumatic stress, combat operational stress, depression, and suicidality. Presenters will address the unique stressors confronting service members during deployment including situational threats of combat as well as common deployment‐related psychosocial and behavioral factors that affect transition post‐
deployment and impact help‐seeking and responsiveness to healthcare and mental health interventions. Learning Objectives: Participants will be able to:  Identify at least three military cultural issues that contribute to the complexity of mental health needs in Service Members and Veterans.  Demonstrate understanding of the effects of the military culture’s power and authority structure on the attitudes, values, and help‐seeking behavior of Service Members and Veterans and the implications for client participation in assessment and intervention.  Articulate the importance of alignment with the military decision‐making process concerning assessment and intervention options for military Service Members. 3 
Demonstrate awareness of the importance of including appropriate resources with specialized knowledge of military culture in case planning and management for Veterans and describe methods for identification of such resources. Title: The Importance of Family and Community in Responding to Moral Injury (breakout session: 1430 – 1545) Presenters: William Nash, MD, Dianne Lethaby, Laila Halaby, Dean Pedrotti Description: A panel of military and VA clinicians and community representatives will explore the community’s societal role in the process of moral repair of military veterans who return to home with moral injury. The importance of educating military families and the community at large about emotional states such as shame, guilt, depression, anxiety, anger, and numbed or conflicted feelings as well as behaviors such as substance misuse, suicidal ideation, social instability, and inability to trust others will be discussed. Resources that show promise in supporting moral repair will be examined. Learning Objectives  Describe at least four common expressions of the “stress resulting from perpetrating, or merely witnessing, acts — or failures to act — that transgress deeply held, communally shared moral beliefs and expectations.” (William P. Nash, MD)  Describe potential impacts of combat‐related moral injury on a Service Member’s/Veteran’s relationships with family and community.  Articulate the role of education on developing the capacity of military families to understand moral injury and support moral repair.  Demonstrate an awareness of promising approaches to moral repair and the value of community‐based opportunities for meaning‐making activities that support moral reconstruction. 4