• Find out more at UCSF and connect with Dr. Maguen on LinkedIn.

Joe Sanok 00:00:00  I'm so excited to introduce you to the best website designers out there. We have a brand new partnership with session sites. It is where good therapy meets brilliant design, and they get your website switched over or built in less than two weeks. They fine tune your messaging, use science backed user experience methodology, and work exclusively with mental health professionals. In fact, new clients right now are going to get three free therapy marketing strategy calls with their creative director of session sites. If you book today, you're not going to want to miss this. Head on over to session sites. Com forward slash Joe again that session sites.com/joe get the website of your dreams today session sites.com/joe. This is the practice of the practice podcast with Joe Sarna accession number 1187. I'm Joe Cenac, your host, and welcome to the practice of the Practice podcast. We have been talking about the brain. We've been talking about trauma. We've been talking about creativity. We've been talking about language. And today we're going to be talking about veterans and moral injury.

Joe Sanok 00:01:23  So it's going to be another fascinating discussion. Really excited for this. You know here at practice of the practice, we want to help you build a thriving private practice that you absolutely love. Whether you are just getting started, maybe you want to build a sustainable solo practice. maybe you want to add one person in to have a small group practice. and you're launching that group practice. Or maybe you're already a group practice. Boss, we have something for you. So we have our membership communities. If you have never dug into these, you're going to want to head over to practice of the practice.com/membership. this is a great way for you to get connected with other therapists at your phase of practice. Pick a track based on where you're at. Are you solo? Are you starting a group? Do you have a group? it's a great place to get connected with everyone, here at practice of the practice. So practice the practice.com/membership. Well, I am so excited to have Doctor Shira again with me.

Joe Sanok 00:02:19  Shira is the mental health director for the post 911 Integrated Care Clinic at the San Francisco VA Health Care System. She is a professor at UCSF and a leading researcher in PTSD, moral injury, and suicide among veterans with a focus on women. Doctor McGann has received numerous grants to study and develop treatments for these conditions, and she's the author of over 190 peer reviewed publications. She also provides clinical care to veterans and supervises trainees in evidence based PTSD treatments. Shira, welcome to the Practice of Practice podcast.

Dr. Shira Maguen 00:02:58  Thank you so much. It's such a pleasure to be here.

Joe Sanok 00:03:01  190 peer reviewed publications. Wow, you couldn't have done ten more to get to 200. No, I'm just kidding. That's amazing.

Dr. Shira Maguen 00:03:09  Thank you, thank you.

Joe Sanok 00:03:11  Yeah. Wow. man, I would just love to start with, like, why did you pick trauma to be your focus area?

Dr. Shira Maguen 00:03:19  Yeah. So I think, you know, one thing that I actually started working in HIV, in my early career, and it was, you know, trauma was everywhere.

Dr. Shira Maguen 00:03:31  And as I got further and further into my training and my studies, no matter which area I was focusing on, trauma seemed to really be the overarching theme for so much of what was happening to people and the lens through which they were seeing their experiences and seemed so critical. So that's really what got me started. And and really, that naturally led to working with veterans.

Joe Sanok 00:03:57  yeah.

Joe Sanok 00:03:58  Well, you use the term when we were talking and also in your bio moral injury. let's just start there. And maybe there's other terms that you think it's important to just define at the top of the show. tell us about moral injury and other terms that you think are important for us to know as we dig into this conversation.

Dr. Shira Maguen 00:04:16  Great. So moral injury is a great place to start. And I can define that. So the definition that I typically use is perpetrating, failing to prevent or witnessing acts that transgress deeply held moral beliefs or expectations. And so I'm going to break that down. So this is what we really mean by that is you do something, you fail to do something or you witness something that goes against your morals and values.

Dr. Shira Maguen 00:04:46  So that has to be present for moral injury to occur. There has to be some kind of a line that the individual feels like they crossed. And then typically what comes after that are symptoms like guilt, shame, withdrawal, the inability to self forgive. And sometimes we also see self-sabotaging behaviors as well. If a person feels like they did something that was wrong, they may feel like they don't deserve to be happy or they deserve to suffer as well. So we see a lot of ramifications of some of those beliefs in their behaviors as well.

Joe Sanok 00:05:24  Yeah. so are there other definitions that we need to make sure we hit on, before we get too far in?

Dr. Shira Maguen 00:05:31  So I think, you know, other definitions that have been offered. So I think that's really the main one that I have thought about when I think about moral injury. I think there is also a lot of discussion about how betrayal, plays into moral injury as well. So particularly institutional betrayal, if people feel like they were supported. and I think that that we really saw that playing out, for example, during the pandemic, and during the Covid 19 pandemic, specifically when, you know, health care workers felt like institutions that they were working in weren't fully supportive.

Dr. Shira Maguen 00:06:09  And, you know, that the government wasn't fully supportive. So this gets into more complicated areas. But I think really, you know, the the core definition of moral injury that we like to really work with is really that the individual crossed some kind of a line for them in terms of their morals and values. and I'll, I'll say to that, people often ask me, well, moral injury seems like something that is unique. How does that interface with, diagnosable conditions? And so I'll clarify too, that oftentimes we do see moral injury that just happens in and of itself, but that we also frequently see that moral injury can travel with post-traumatic stress disorder, with depression, with substance abuse. so it can be travel by itself, or it can also travel with some of those, conditions as well.

Joe Sanok 00:07:05  so what are some examples of, vets that you've worked with and how moral injury has occurred?

Dr. Shira Maguen 00:07:11  Yeah. So I think that, the most frequent experience that I worked with, and really what inspired me to get into this line of work is veterans who struggle with the impact of killing in war, specifically.

Dr. Shira Maguen 00:07:25  so I'll share that when I first started to do this work. it was right after September 11th. And, and then as more and more vets were going off to serve in the Middle East and then coming back, you know, we had evidence based PTSD, psychotherapies that we were, that we were doing with veterans who came back and to deal with their PTSD. And yet there seemed to be an additional piece that they were really struggling with. And so the veterans that I was seeing in therapy at that time. one of them particularly was struggling with the impact of killing. This particular veteran had killed a child in in war, who had threatened him. And as a result, when he came back home, had his own child who reminded him of that child that he had killed in war and was really struggling. Every time he looked at his child, it would remind him of what had happened. and he was really stuck and unable to to lead a successful life and to integrate back into society after that happened.

Dr. Shira Maguen 00:08:34  And so this really got me thinking very deeply about how, you know, maybe we need something additional, to ways to talk about people's experiences that wasn't only about PTSD, but when a step further in terms of what they did in war and really looking at that, in therapy.

Joe Sanok 00:08:56  Yeah. I can't imagine that. so you've done a lot of research in regards to kind of what works. I always love having experts like yourself just kind of give almost a short masterclass, you know, just like 3 to 5 points on on trauma and veterans. like, if, if you could be like the go to for grad schools for just a micro training here's like the quick and dirty that every therapist in the world should know this. when it comes to veterans and trauma and moral injury, like, what's the the 3 to 5 things that you're just like, seriously, like, everyone needs to have a working knowledge of this.

Dr. Shira Maguen 00:09:36  Yes, I that's a great question. So I think the first piece is really understanding what's happening for a particular veteran.

Dr. Shira Maguen 00:09:43  So sometimes you mentioned trauma and you mentioned moral injury. And so I think the first step is really good assessment of what the person is struggling with. Right. So we we see plenty of people that just have PTSD when they return for more. And then we see plenty of people who may have moral injury or a combination of the two of those or even other comorbid conditions as well. Right. And so I would say that the first piece is if you suspect that something is going on, you know, we have excellent measurements for both PTSD and moral injury now. So I recommend, you know, if you're the the PTSD checklist five for assessing, PTSD. Also, if you're doing a clinical interview the Caps five the clinical interview for DSM, five is an excellent tool as well. So to get really good assessment for PTSD and then for moral injury, we worked very closely. I worked closely with colleagues from the National Center for PTSD and also the VA and little Rock to develop a measure for moral injury called the Moral Injury and distress scale or the mids.

Dr. Shira Maguen 00:10:59  And so that is a great tool. We validated that with veterans but also with health care workers and first responders. And that's a great way to assess moral injury. That really allows us to assess both for the exposure to the events that the person experience as well as the symptoms of moral injury. So those two are very important that those two go hand in hand. So I would say that that's step number one. Get a clear assessment of what the veteran is presenting with. And then from there I think that, you know, the types of treatments that can be matched to that are critical. So where I work at the San Francisco VA, we make sure that veterans are are ready. But then, you know, for psychotherapies. And when they are, we believe that very good psychotherapies include things like cognitive processing therapy and prolonged exposure therapy. Those are both treatments that allow people to deal directly with what happened to them with a traumatic event and talk about it in terms of the experience, as well as the thoughts and behaviors that follow.

Dr. Shira Maguen 00:12:15  And so these are both cognitive behavioral treatments that are have very strong evidence. And we highly recommend those for moral injury. I think that the that there is emerging treatments that have some studies and some support, but the evidence is growing every day. And so I think that with moral injury, the treatments include a number of different treatments that are in development, including one that we developed called the impact of killing for veterans who have killed in war. There's also an intervention called trigger for people who are experiencing guilt and shame. There's also a treatment called adaptive disclosure as well. for people who are struggling more with the spiritual component, there are also a number of different treatments that that have focused on, spirituality as well. So I can go on. But those are just a few of the treatments that are currently in development right now. And so hopefully we'll be seeing more and more evidence for those in the future.

Joe Sanok 00:13:24  so it sounds like there's the assessment side of making sure to really understand, what types of scales and measures can help you understand what's going on with the veteran and then pairing up the treatment that's best for them with that, with these emerging treatments?

Dr. Shira Maguen 00:13:40  That's exactly right.

Dr. Shira Maguen 00:13:41  Yeah. Some are on the moral injury side. It's it's more emerging. There's some evidence. But I would say there's very strong evidence for how we treat PTSD. That's exactly right.

Joe Sanok 00:13:53  And like what is what is recovery look like for veterans? I mean, I would imagine and tell me if I'm wrong, that some of some veterans may be some barriers to their recovery would be them thinking, well, this is what I signed up for. It's like I knew I was going into the military and then feeling like, why am I dealing with all of this stuff when I knew what I was going into like first? Is that true? And then also like, what are other kind of maybe mindsets or barriers they have to work through through that recovery process?

Dr. Shira Maguen 00:14:22  Yeah. So you're absolutely right that one of the biggest barrier is just even getting to the treatment. and so stigma is a huge barrier. People feeling like they should be able to heal on their own. that just getting people to the therapy room, I would say is a huge feat a lot of times.

Dr. Shira Maguen 00:14:41  And what we see over and over again is that it's loved ones that really motivate people to get into treatment. So partners and family members, and so I would say to you, if, if you're a partner or family member out who's listening right now to to this podcast and you know, you have a veteran who who needs help, like you're going to be oftentimes their biggest motivation. Right. And so I think that that's a big thing to remember to what we can do to to counteract some of that stigma as well. And I think, you know, we, you know, one of the clinics that we have at our VA, really tries to counteract that stigma by including mental health as part of our post 911 Integrated Care clinic. So when a veteran comes in who is post 911 for primary care, they automatically get mental health and social work wrapped into that. And that's, you know, one way that we have found for counteracting some of that stigma and just getting people automatically connected to mental health as if to say, you know, we give this to everyone.

Dr. Shira Maguen 00:15:53  You don't have to be struggling to have a check in about your mental health. So that's one thing that we've done to to try and counteract some of the stigma that people hold. but other yeah, I think other barriers also just include that, you know, many people have busy lives. And to to carve out time for some of these treatments is is challenging. some of the treatments are for PTSD and specifically are weekly and some are 60 to 90 minutes. and so it really does require and there's outside of session work. And so I think a lot of times those can be barriers to, to, really having people participate. And then I think just the fact that, you know, if you have PTSD you've been avoiding for so long, what happened to that? It can be very frightening and scary for people to think about going back there if they've kind of, you know, put that box, try to put that in a box and put it away. So to open that back up can feel very scary for people, both in terms of PTSD and also in terms of moral injury treatment as well.

Joe Sanok 00:17:01  Absolutely. Listen, I didn't take insurance in my counseling practice because I had no idea how to handle it. The process of accepting insurance outside of a group practice can be tough, but most people looking for mental health care want to use their benefits to pay for sessions. If you're like me and you feel a little scared about taking insurance, or you just want to make it easier on yourself and you're interested in seeing clients through insurance, alma can help. They make it easy to get credentialed with major insurance plans at enhanced reimbursement rates. They also handle all the paperwork, from eligibility checks to claim submission and guaranteed payment within two weeks. Plus, when you join Alma, you'll get access to time saving tools for intake scheduling, treatment plans, progress notes and more in there included platform. It's going to make it so much easier for your team so you can spend less time on administrative work and more time offering great care to your clients. Visit. Hello, alma. Com slash. Jo. That's. Hello, al.

Joe Sanok 00:18:07  Macomb. Jo. To get started. So when you think about the next kind of phase of helping vets, what do you see as being as being kind of the next steps?

Dr. Shira Maguen 00:18:21  Yeah. So I think in terms of I'll focus on moral injury because I think that there's, you know, in some ways the study of PTSD is more advanced than moral injury. So I'll pause to say that the idea of moral injury has been in other disciplines for many, many years. So philosophers have been kind of talking about this idea of moral injury, not necessarily using those exact words, but for many years. And, it can be found in philosophy going very far back. But I think that mental health is really fairly new to being able to define moral injury and measure it and also treat it. And so I think in terms of the future, the most work that we have to do is really in understanding the full presentation of moral injury, and then how people who may hold different identities may have different presentations of moral injury, and also how to treat how to best treat moral injury as well.

Dr. Shira Maguen 00:19:26  So as I mentioned before, we have a number of treatments, but I think we really have a lot of work to do in best tailoring some of those moral injury treatments to both the moral in the both the type of moral injury, but also to the individual as well. So those are a few things that I see really developing in the future. I think also in terms of the future, the most work in moral injury has been done in veterans. And so I think in the future we're really going to see an expansion of research and hopefully clinical work as well that is targeted towards other groups like health care workers and first responders, who we know have lots of potentially morally injurious events as part of their work. And the treatments that I shared with you have mostly been developed with veterans. And so right now, the moral injury treatments for other groups are quite minimal. And I see that as a big area of expansion as well.

Joe Sanok 00:20:30  Yeah. For you personally. what are aspects of the research that is really standing out to you or that it's getting you excited?

Dr. Shira Maguen 00:20:38  So I think what is what we're working on right now is collaborations that are global with moral injury.

Dr. Shira Maguen 00:20:47  So what we have found, as we, you know, go to meetings where we present some of our findings is that the term moral injury really resonates, not only, you know, across groups, but also across countries as well. And so we've had a lot of people who have approached us and said this, this really resonates with me, or this is something that I can really see applying to my work, either with veterans or other groups as well. and so I think that what I find really exciting is how much that resonates with people across groups, and also to really understand from an international perspective as well, how this affects different people and different cultures. So I think we have a lot to learn there, but to me that is quite exciting to delve into that and really understand this from a cross-cultural perspective.

Joe Sanok 00:21:44  yeah.

Joe Sanok 00:21:45  Now I'm picturing some of our, clinicians that are in more rural areas that maybe the vets that live in those areas don't have access to maybe the same level of care or specialty as some of the larger kind of more urban areas.

Joe Sanok 00:22:01  what are some either techniques or mindsets or things that, that therapists that are have a vet that they're working with and maybe they aren't a specialist in some of the modalities you're talking about. kind of whenever I interview experts, I guess it's kind of what I'm getting at is there's sometimes things that it's like, you definitely should go see an expert in this area. Don't mess around with it. Like, don't pretend like you are an eMDR expert. Go get trained in eMDR if you want to do that. So there's like that category of definitely get training. And then there's other areas where you can learn principles that apply to any vet dealing with moral injury or trauma. And it's like, we would love to have these people have models and training in deeper areas, but if they're the only one that's really working with vets in their community, we'd at least like them to have these 3 to 5 things that, you know, they're pretty good at. for those people that maybe, haven't had a ton of the extra training, and they're in those situations where they're working with veterans, like, how much should they be referring out? Or, you know, pushing tele therapy.

Joe Sanok 00:23:03  That's maybe for someone that has different training versus them having these, these trainings, from things like the podcast or other things, that, that they can be competent enough as a clinician, to then help those vets. That was a big mess of a question.

Dr. Shira Maguen 00:23:19  No, I appreciate that. so I think that there's a couple of things. So I think that, there the I know the VA has done a lot of work to try and expand a number of treatments to veterans in rural areas and hard to reach areas. And so, what's, you know, one thing that has come out of the pandemic is that there is a lot more, connected care. Right? So, the ability to, to really deliver treatments to veterans in more rural areas, of course, that depends on them being able to get connected through the internet and a number of different things. But I think there is now people who can work with them to, to make sure that they can get to connect it to the best of their ability.

Dr. Shira Maguen 00:24:06  And so I do think that as these treatments become more widely available, that is a great option, to really receive remote care for some of these conditions. Now, that being said, I, I will also say, you know, that as the treatments grow and expand, they'll probably be more trainings for therapists. So I think that's a wonderful thing to to be able to do if you can join a training. that's fantastic. Also, you know, the National Center for PTSD has information posted about moral injury. So to, just to even to start to have veterans read about this and see if it fits for them on websites like that I think is a is a great step too. and then I think the other thing that I'll mention is, you know, part of treating moral injuries, also building bridges with other groups. Right. And so we know that, for example, spiritual communities do a lot of work with veterans as well. And that's been a great source. And so sometimes particularly veterans are struggling with some of the spiritual issues.

Dr. Shira Maguen 00:25:14  You know, it doesn't have to only be therapists that connect with veterans sometimes, especially if spiritual communities and clergy are are well trained in moral injury. And I think certainly in the VA system, there's more and more training of those groups to really work with moral injury. I think that that can be a really good way to sort of build bridges, so it doesn't feel like it's, you know, only the therapist who is doing the work that it really is sort of a an issue that the veteran can get care for in other places as well. I will also say that there are now some models where veterans share some of their experiences with community members as well, and there are some rituals through groups that have happened through that work. And so I think that that's another option. Again, not it could be either that the person connects remotely to that kind of, activity or that they can attend that at their local VA as well. So I think that there's for rural veterans, again, there's a number of options, either getting connected remotely through telehealth or their therapist doing a training, or them going to sites like the National Center for PTSD.

Dr. Shira Maguen 00:26:31  I know that soon there's also going to be something that's launched, through the National Center for PTSD that, are videos of people with moral injury sharing about their experiences specifically. And so that can be a really good option for veterans to to watch other veterans who have struggled with this issue just to make sure that this is what they're experiencing, and to really be able to see other veterans who have gone through treatment and who have struggled with these issues as well. So I know that's, a lot of different possibilities, but I think that gives us some choices to work with.

Joe Sanok 00:27:10  So awesome.

Joe Sanok 00:27:11  Well, the last question I always ask is if every private practitioner in the world were listening right now, what would you want them to know.

Dr. Shira Maguen 00:27:18  So I think that what I would want them to know is often by just being able to use the language of moral injury, that can go a very long way. So just by having the conversation, what we found is that the language really resonates with many veterans and that it opens up many doors to, to name the experience that they may be having.

Dr. Shira Maguen 00:27:45  And so I really recommend just sort of exploring whether this fits for people. And if so, I think that oftentimes it will open up the conversation to go to a deeper level about people's experiences that they, you know, many of whom haven't shared those experiences before. So so that's maybe what I would leave people with. And then just the last thing, again, I think this I mentioned this prior, but, you know, to involve family members and loved ones is always a good idea because I think it, again, and that doesn't mean that the veteran needs to disclose to any of those people, but just to involve them in sort of being able to have the veteran get into treatment and in some of the follow up can be a really good idea, just so that the veteran feels supported in doing this work. And it doesn't have to be a secret that they're doing some of this work, I think goes a long way.

Joe Sanok 00:28:42  So awesome. I love that idea of community involvement and community support.

Joe Sanok 00:28:46  And, you know, people that love these veterans and allowing them, to to just be, connected with, thank you so much for the work that you do. If people want to connect with you, if they want to read more about, you know, the work that you're doing, what? Where should we send them?

Dr. Shira Maguen 00:29:00  Yeah. So I would love to connect through people, on LinkedIn. So please feel free to find me there. I also can be reached at Shira magen at VA gov, which is my email. So any of those are great options.

Joe Sanok 00:29:17  So awesome. Thank you so much for being on the show.

Dr. Shira Maguen 00:29:20  Thank you for having me create conversation.

Joe Sanok 00:29:26  And.

Joe Sanok 00:29:32  What a great, interview. And, so exciting to just be learning how we can think about our brains and our clients brains and our friends brains, just in different ways. The group practice boss conference kicks off May 6th and seventh here in Traverse City, Michigan. if you have not got your tickets for it, I imagine that the in-person tickets are probably sold out by now.

Joe Sanok 00:29:56  but you can, look at the live stream and all those all that information over at practice of the practice.com/conference, to get your live stream ticket there. all sorts of things to prep. coming up, in that last week before you come out to Traverse City. I know, a bunch of you are coming at the time of this recording, which is actually in late 2024, we're pretty far ahead. half of our tickets are sold for the group Practice Bass conference. We're super excited because we think 2026, is going to be even bigger. We want to host that over, where Ted is hosted in this beautiful auditorium in an art, art gallery. So, look out for that in the future. also, thank you so much to alma for being our sponsor today. You know, I wish alma had been around when I had my private practice. I had no idea what I was doing. That's why I didn't take insurance. But if alma had been there, I would have. And there's no reason that as a clinician, you should be spending hours on paperwork to bill for insurance or not knowing for sure that you'll get reimbursed for sessions with your clients.

Joe Sanok 00:30:58  If you're interested in seeing clients through insurance but don't want to navigate the process and paperwork on your own. Alma can help. They make it easy to get credentialed with major insurance plans at enhanced reimbursement rates, and a guaranteed payment within two weeks. Visit. Hello. Alma com slash Jo. That's hello alma com slash Joe to get started. Thanks so much for letting me into your ears and into your brain. Have a great day. I'll talk to you soon. Special thanks to the band Silences Sexy for that intro music. And this podcast is designed to provide accurate and authoritative information in regard to the subject matter covered. It is given with the understanding that neither the host, the producers, the publishers or guests are rendering legal, accounting, clinical or other professional information. If you want a professional, you should find one.